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URINE, TJRINAEY DEPOSITS, 

AND 

CALCULI, 

AND ON THE TREATMENT OF URINARY DISEASES. 



URWE, URINARY DEPOSITS, 

AND 

CALCULI; 

AND ON THE TKEATMENT OF 
UEINARY DISEASES. 

WITH NUMEROUS ILLUSTRATIONS, AND TABLES FOR THE 
CLINICAL EXAMINATION OF URINE. 

BY 

LIONEL S. BEALE, M.B., F.R.S., 

rsLLOv or thx eotal collbos of rBTsiciAMS; rHTHciAK TO kino's collxob bobpitai. : 

PBOVXSSOB OF PBT8IOLOOT AMD OV OEMBBAL AHS KOBBID AMATOMI IM, AVI> 
■OKOBABT FBX.I.OV OF, KIVO'S COLLBOB, LOMOOK. 



SECOND EDITION. 




LONDON: 
JOHN CHURCHILL & SONS, NEW BURLINGTON STREET. 

MDCCCLXIY. 
IThe right of Translation is reserved.} 






I 



w 




westxinstxb: 

PBI5TED BT W. BLAarCHABD A5D 80X8, 
62, KILLBANK 8TBBET. 




DEDIOATED TO THOSE WHO 

WORKED WITH THE AUTHOR IN HIS LABORATORY, 

AlTD AT A YEBT EAKLT PEBIOD OF HIS OAREEB 

GAVE HIM THE 

WABMEST ENOOUBAGEMENT AND SUPPORT. 



1852. 



/ • 




PEEFACE 



THE SECOND EDITION. 



The Author has endeavoured to increase the usefulness of 
the Work by the addition of observations on the treatment of 
urinary diseases. Experience has taught him that the treatment 
of many chronic and obstinate diseases of this class is more suc- 
cessfully carried out by attention to the general physiological 
changes going on in the system, and by the use of simple remedies 
in suitable doses, given regularly, and persevered with for a con- 
siderable time, than by the employment and frequent change of 
complex formulsB. In common with many physicians, the Author 
feels that the treatment of disease may now be conducted upon 
well recognised and intelligible principles, and that the system of 
ordering a number of different substances should be deprecated, 
because evidence has proved it to be useless to the patient, whilst 
it must foster mystery in connexion with our art, and greatly 
retard the advance of medicine. The reader will, therefore, not 
find a list of all the drugs that have been advocated as having 
a special influence on the urinary organs; nor will he meet with 
complex recipes containing several different ingredients, the action 
of which is very imperfectly understood. 

A 3 



X PREFACE TO THE SECOND EDITION. 

The general arrangement of the urinary deposits adopted in 
the first edition has been retained, as increased experience in 
teaching has convinced the author of its real practical utility. 
If the reader will refer to the arrangement of the contents in 
page xL, he will readily find any subject he requires. In addition, 
however, a copious index has been made. New observations and 
several new figures have been introduced, and a considerable part 
of the work has been entirely re-written, while new matter, to 
the extent of nearly 100 pages, has been added. 

For the sake of convenience, and for cheapness, the work has 
been published in the form of a Hand-book, but it contains much 
original matter, and the results of greater labour than the reader 
would be led to suppose from a superficial review of the contents. 



61, Grosvbnob Stkkbt, W., 
October 1st, 1863. 






PREFACE 

TO 

THE FIRST EDITION. 



The Lectures which axe now published were first given in 
November, 1852, at a laboratory adjoining King's College Hos- 
pital (27, Carey Street, Lincoln's Inn Fields), which I had arranged 
for the study of those branches of chemistry and microscopical 
inquiry which have a special bearing on medicine. Several courses 
of lectures and demonstrations were given during the seven suc- 
ceeding years; but of late, increased work in other departments 
has prevented me from devoting so much of my time to this 
branch of teaching. 

The course on urine included oral lectures and practical 
demonstrations, in which every pupil performed the experiments 
with his own hands, according to the directions given in the 
Tables, which will be found at page 411 of the present work. 

The lectures were first published in the British Medical Jour- 
naJy and are now printed in a collected form, with several additions. 
I have endeavoured to restrict myself, as far as possible, to those 
parts of the subject which are of practical importance in investi- 
gating the nature of a case. It must be borne in mind that the 
Lectures were given to practitioners, most of whom had far larger 
experience in practice than myself. Little advantage, therefore, 
could have resulted under these circumstances from discussing 
special questions connected with the treatment of disease, and 
almost the whole time was devoted to the practical examination of 



/ 




PREFACE TO THE FIRST EDITION. 

the urine and urinary deposits by the microscope, and by applying 
the appropriate tests. I have thought it right to retain this 
character in the present work, and only a few very general remarks 
will be found with reference to the treatment of urinary diseases. 

I have had frequent occasion to refer to numerous works, and 
have inserted many references in the text between brackets. The 
names of almost all the authors consulted will also be found in 
the index. 

Nearly all the analyses have been made by myself, and the 
drawings have in most cases been copied by me on the blocks, 
which were afterwards engraved. Those illustrating the chapter 
on the kidnejr have been very recently copied from specimens 
carefully prepared. Only comparatively few illustrations of the 
salts of the urine and of urinary deposits will be found in this 
work, as they have been already published in the "Illustrations" 
to which frequent references will be found. I have endeavoured, 
as far as possible, to give accurate copies of the objects; and almost 
all the drawings have been traced directly on the wood-blocks or 
lithographic stones. Each object has been represented of the 
exact size it appeared. The magnifying power is given, and a 
scale appended, by which anyone can measure each object. 

References to different parts of the work are inserted where 

required, especially in the Tables at the end of the volume. Pains 

have been taken to arrange the subjects to be discussed in the 

most convenient manner. A glance at the arrangement which 

immediately follows will at once give the reader an idea of the 

contents of the book, and the order in which the subjects are 

treated of. 

Lionel S. Beale. 

61, Grostbnob Street, W., 
March, 1861. 



^^#, 



AERANGEMENT OF CONTENTS. 



CHEMICAL AND MICROSCOPICAL APPARATUS FOR 
THE CLINICAL EXAMINATION OF URINE. 

I. — Chbmioal Apparatus. 

PAOB 

Balance^ Tf^^ and Measures — Test-tubes and Holders — R«tort-stands 
— Tripods — Spirit-lamp — Waier-halh — Beakers — Conical Glasses — 
Evaporating-basiits — Wash-bottles — Glass Funnels — FUtering-paper 
— Measures — Test-paper — Urinometer — Blow-pipes — Pipettes — 
Watch-glasses — Brass Forceps 1 



Tests. 



Alcohol 
Sulphuric Acid 
Hydrochloric Acid 
Kitric Add 
Oxalic Acid 
Acetic Acid 

ATwmm^ift 

Oxalate of Ammonia 

Potash 

Ferroeyanide of Potassiam 

Chloride of Ammonium 



lime Water 
Carbonate of Soda 
Phosphate of Soda 
Chloride of Calcium 
Chloride of Barium 
Perchloride of Iron 
Sulphate of Copper 
Kitrate of Silver 
Bichloride of Mercury 
Bichloride of Platinum 
Barreswil's Solution 



II. — MiOBOSOOPB AND ApPABATUS. 

Clinical Pocket Microscope— student's Microscope— 06^-^^«8s— 
Stage Miorometer — Neutral-tint Glass R^Udor — Microscope Lamp 
—Test^tUes, with Capillary Orifices— Glass Slides— Thin Glass- 
Glass Cells , ' 



XIV AERANGEMENT OP CONTENTS. 

THE VOLUMETRIC PROCESS OF ANALYSIS. 
I. — The Appabatus. 

PAGB 

Burettes — Pipettes — Cflass Measures — Beakers — Weights and Measures . 1 2 

II. — The Proobss. 

ITrea— Chlorides— Preparation of the Solutions— Phosphoric Acid— 

Sulphuric Acid —Sugar 14 

Davy^s Method of determining Urea 21 



EXAMINATION AND PRESERVATION OF URINARY 

DEPOSITS. 

I. — Examination of Urine, &c 

Period when it should he Examined — Removal of the Deposit — 
Magnifying Powers required — Chemical Examination of Urinary 
Deposits 25 

II. — The Preservation of Deposits. 

Of Preservative Fluids in which Deposits may he kept permanently — 

on Preserving Crystals 30 

III. — Of Extraneous Matters Aooidentally Present in Urine. 

Larva of Bhw-fly — Hair — Cotton and Flax Fibres — Fibres of Deal — 
Starch — Tea Leaves — MiUe — Sputum — Epithdiam from the Mouth 
— VomU 37 



THE ANATOMY OF THE KIDNEY, AND ITS ACTION 

IN HEALTH AND DISEASE. 

I. — Anatomt. 

Cortical and Medullary Portions of Kidney — Pelvis — Mamilla — Infitnr 
dibula and Calyces — Artery — Vein — Nerves — Lt/mphatics — TJrini- 
ferons Tnhet—Epithelinm— Matrix— Circulation in the Kidn^ 
— On some Points connected with the Physiology of the Kidney . 44 

II. — The Forxatioh of Casts of the Uriniferous Tubiss . 57 

III.~Moebid Chanqbs in Struotueb. 

Of Bright's Disease— Dr. O. Johnson's Researches . . . . ^Q 



ABRANaEMENT OF CONTEITrS. XV 

URINE m HEALTH. 

PAOB 

Oeneral Charaotera— Note-book— Seaction— Specific Gravity- 
Add ITrine— Alkaline ITrine 71 



I. — VOLATILB COFSTITUBKTS. 

Water— Carbonic Acid— Organic Acids— Ammonia. 
II. — Oroaitio Cofstitukhts. 

ITrea — Guanine — Saretm — InosUe — ITrio Add — ffippnric Add — 

JEixtraetwe Matters — LousHc Add and Lactates . . . . 85 



HI. — Ikorqahio Cokstituents. 

Alkaline FhoBphates— Earthy Phosphates— Sulphates— Chloride of 
Sodium — \Soda and Potash — Lime — Magnesia — Iron — Silica — 
Alumina 107 



SYSTEMATIC QUALITATIVE, OB QUANTITATIVE ANALYSIS OF 
HEALTHY UBINE. 

L — Obqahic CoHSTEnnBHTfl 104 

IL — ^iHoaoAnc CovsTinnniTS 127 



COMPOSITION OF HEALTHY UBINE, AND THE QUANTITY OF 
THE DIFFEBENT CONSTITUENTS EXCBETED IN TWENTY-FOUB 
H0UB3 130 



ARRAI7GEMENT OF CONTENTS. 



URINE IN DISEASE. 

PAGE 

I.— On Diathbsis 141 

II.— EXQKSS OR PbPIOIENCY Olf WATER AND THE ORGANIC 

Constituents. 

Diabetes Insipidxis — Increased Acidity — Nitrio Acid in Urine — 
Ammonia — Urea — Urine in Chorea^ ^c — Colouring Matter — 
Uric Acid 139 



III. — Excess or Depicibnct op the Inorganic Constituents. 

Chloride of Sodium, its diminution in Acute Inflammation — SnlphateSi 
increase in Rheumatic Fever — Alkaline Phosphate — Urine in 
InJIammMion of Brain — Mania — Delirium Tremens — Epilepsy — 
Paralysis of the Tissues — ^Earthy Phosphates — Urine in moUiiies 
ossium 

Frinoipal Points to be ascertained from a quantitative Analysis 

of TTrine in Disease 189 



171 



IV. — SOLUBLB SUBSTANOBS PRESENT IN UrINB IN DISEASE, WHICH 
DO NOT EXIST IN THE HbAI,THT ^ECR^TION, 

Albomen — Tests — Anomalous results — Apparent Presence of Albumen 
in Urine which contains none — Apparent Absence of Albumen when 
actually present — Peculiar Substance allied to Albumen — Clinical 
Importance (f Albumen — ^Bile — Tests — Yellow Colour of Cells, &c., 
in Deposits . . . . 191 



V. — Soluble Substanobs which do not exist in the Hbaltht 
Secretion. 

•»■ 
Diabetie Sugar-— Tests for Sugar— Estimation of the Quantity of Sugar 
— TheNatore and Treatment of Diabetes — ^Alcapton — ^Leucine — 
Tyrosine— Inoiite— Acetone— Cystine ,217 



ARRANGEMENT OF CONTENTS. 



URINE IN DISEASE— INSOLUBLE MATTERS. 

I. — SUBSTAKOBS FLOATING ON THE SUEFAOB OF THB UbINB, OR 

Diffused thbough it. 



PAGE 



Thin pellicle — Opalescent Urine — Vibriones — Milk in Urine — Chylous 

TJnDB—Analyses of Chylous Urine— Treatment . . . .267 

Fatty matter in Urine— Different Forms : 1, Molecular; 2, As free 
Gkhtdes'f 3, Globules in Cells; 4, Dissobjed in otJier Constituents; 5, 
As Concretions; 6, In a fluid «tote—CholeBterine— Fatty Matter in 
Cases of Fatty Degeneration of the Kidney— Kiestem TTrostealitli 282 



II. — Of Light and Flooouibnt Deposits. 

Mncns — Vibriones — ^TomlaB — Sugar Fungus — PenicUium Glaucum — 
Sardna — Trichomonas Vagina — Epithelium from Ureter, Bladder, 
Urethra f or Vagina — Spermatozoa — Vegetable Bodies resembling 
Spermatozoa 289 

Casts of the tubes. 

A Cf Medium Diameter — Epithelial Casts— Casts containing 
Dumb-bells — Granular Epithelial Casts — Casts containing Oil 
— Fat-cells — Casts containing Blood or Pus. B. Of Consider- 
able Diameter — Large Waxy Casts. C. Cf Small Diameter 
— Small Waxy Casts — Of Casts in a Clinical point of view . 305 



III.— Of Dense and Opaque Deposits. 

Urates, Pus, and Phosphates — ^TTrates — Albumen present — Analyses — 
Pns— Tferfs— Of Pus in a Clinical point of view— Earthy Phos- 
phlites — Tr^le or Ammoniaco-magnesian Phosphate — Tests — Phos- 
phaU of Ume in the form of Spherules or Dumb-bells — Peculiar 
forms of Phosphate — On the Crystalline Form of Phosphate of Lime 313 



XVm ARRANGEMENT OP CONTENTS. 

IV. — Graniilab akd Crtstailinb Deposits. 

FAGB 

ITriO hlMr— Crystalline Forms — Tests — diniecU Importance — Oxalate 
of Lime — Octohedra, Form and Composition— Dumb-bells, of their 
Formation, and the Condition under which they occxu—Oltnical 
/mportonce— Cystine— Analysis— Carbonate of Lime— Blood- 
eorpJUUHeB—Giemical Characters — Clinical Importance — Circular 
SpomleSi closely resembling Blood-corpuscles .... 337 

Cancer Cells — ^Tubercle-corpuscles — Spherical Cells containing Nuclei — 

Small Organic Globules 362 



ENTOZOA. 



Eochinococd— Diplosoma Crenata— Strongylus Gigas— £aro<8 of 

Blow-fly, ^c, 321 



URINARY CALCULI. 

General Considerations — Animal Matter in Calculi — Concentric Layers — 
Classes of Calculi — Chemical Examination — Tests in Small Bottles 
wUh Capillary Orifices 371 

I. — Calottli which leave onlt a Trace op Fixed Residue. 

ITric Add Calculi— Calculi composed of Urates— ITrio oxide— Xanthie 

Oxide— CyBtine— Fibrinous— Eatty Concretions . . .376 

II. — Calculi which leave much Fixed Residue. 

Oxalate of Lime— Earthy Phosphate— Carbonate of Lime— Prostatic 

— Summary of Chemical Characters 380 

III. — Op the OBiaiir ahd Formatiok op Calculi. 

Nature of Nuclei — Relative Frequency of Occurrence — Maturing — 
Importance of Administering Fluids — Of Dissolving CalcuU — 
LiUwUmy — Lithotrity 390 



ARRANGEMENT OP CONTENTS. 



OF THE TREATMENT OF URINARY DISEASES AND 



CALCULOUS DISORDERS. 



Diabetes insipidus . . . 147 
Uric acid in excess . .163 
Certain acute inflammations . 175 
Albuminuria and renal diseases 205 
Jaundice .... 215 
Diabetes .... 253 
Chylous urine . . . 278 
Irritable bladder . . .295 
Leucorrhoea . . . .301 
Spermatorrhoea . . . 303 



Deposits of Urates . 
Deposits of pus 
Deposits of phosphates . 
Deposits of uric acid 
Deposits of oxalate of lime 
Deposits of cystine 
Haematuria . 
Cancer and tubercle 
Calculous disorders 



PAGB 

319 
322 
335 
342 
352 
356 
359 
363 



SUMMARY OF MOST IMPORTANT CONSTITUENTS OF 

URINE IN HEALTH AND DISEASE ... 405 

L — DlBBOTIONS FOR MAKINQ A RoUGH GSKEBAL AkALYSIS OF 

U&INB 406 

II. — Chemical Examination of UEnrB 407 

III.— MiCEosoopioAL Examination of Usinaby Deposits . . 409 



TABLES FOR THE SYSTEMATIC QUALITATIVE 
EXAMINATION OF URINE. 

Tablb I. — General Characters of Urine 411 

Tablb II. — Ssrsteinatio Qualitative Examination— The Qrganie 

Constitoents 413 

Table IIL — ^The Saline Ckmstitnents 415 

Table IV.— Suhetances held in Solation in MorUd ITrine— Albu- 
men, Excess of Urea— Bile— Sugar 418 

Table V. — Chemical Examination of TTrinary Deposits— Pus — 

Urates— Phosphates— Uric Add— Oxalate of Lime . . .420 

Table VI.— Urinary CalouU 422 

Table VII.— Microscopioal Examination of Urinary Deposits . 424 

Weights and Measures 427 

Index 429 



EXPLANATION OF THE PLATES. 



Plate I., p. 2. 



Fig. 

1. Test tnbes, rack and holder. 

2. Retort stand. 

3. Water bath. 

4. Spirit lamp. 



Fig; 
5 Platinum capsale and tripod. 

6. Conical glass and urinometer. 

7. Conical glass and urinometer. 

8. Small water bath. 



Plate II., p. 4. 



9. Removal of deposit from conical glass, 

with pipette. 
10. Wash-bottle. 



11. Apparatus for examining urine. 

12. Filtering paper, folded 



Plate III., p. 6. 



13. FuHnel arranged for filtering. 

14. Pipettes. 

15. Urinometers— A, good; B, imperfect. 

16. Specific gravity bottle. 



17. Clinical microscope-. 

18. Clinical microscope, mounted for class 

demonstration. 

19. Stage of clinical microscope. 



Plate IV., p. 8. 



20. Microscope gas-lamp. 



21. Arrangement of microscope for 
drawing. 



Plate V., following Plate IV. 



22. Neatral tint glass refiector, for 

drawing. 

23. Micrometer divided to thonsandths 

and five thousandths, magnified 
215 diameters. 

24 Cell or cage for examining urinary 
deposits. 

25. Glass cell for examining urinary de- 
ports. 



26. Cell or cage for clinical microscope. 

27. Box of test-bottles, with capillary 

orifices. 

28. Test-bottle, with capillary orifice. 

29. Tubular 8topx>er, with india-rubber 

top for removing drops of test so- 
lutions. 

30. Test-bottle, with capillary orifice. 



Plate VI., p. 12. 



31. Burettes, &c., for volumetric analysis 
of urine. 

82. FUter for filtering off clear solution 
ffom precipitate. 

33. Method of obtaining a very small quan- 
tity of deposit from much fiuid. 



34. To illustrate Dr. Davy's method of es- 

timating urea, afker Dr. Handfield 
Jones. 

35. Compressorium. 



EXPLANATION OF THE PLATES. 



Fig. 

36. Fibres of deal from the floor. 

37. Starch globules. 



?LATB VII., p. 38. 
Fig. 



38. Various extraneous matters, feathers, 
blanket hair, cat's hair, cotton, 
flaz,&c. 



Platb VIII., p. 48. 



39. Section of kidney, showing calyces 

and infondibuia drawn to a scale. 

40. Section of a portion of kidney — a, 

cortical; &, medullary portion ; c, 
pelvis; d.inftmdibnlam; e, opening 
of an infandibalnm into pelvis ; /, 
calyx; or, pyramid; A, mamilla or 
papilla; i, adipose tissue; k, large 
veins divided in making the section. 
Small arteries are also seen cut 
across in different parts of the sec- 
tion, some large branches being 
situated between the cortex and 
medullary portion of the organ. 

41. Arrangement of the secreting struc- 

ture and vessels of the kidney of 



man, magnified about 50 diameters 
— a, Malpighian body; &, Malpi 
ghian artery or afferent vessel ; e, 
efferent vessel; d, capillary net- 
work into which the blood passes 
from the efferent vessel; e, small 
venous radicle which carries off the 
blood after it has traversed the ca- 
pillaries Just alluded to ; /, com- 
mencement of the nriniferous tube 
by a dilated extremity which em- 
braces the vessels of the tuft; ff, 
the nriniferous tube; h, straight 
portion of tube ; «', another tuft ; k, 
portion of a tube cut across, show- 
ing basement membrane. 



Plate IX., p. 52. 



42. Branches coming direct from arteries 

and pasmng into the pyramids of 
the kidney. These vessels have the 
structure of arteries, and are called 
tcua recta. 

43. Thin section from a healthy human 

kidney slightly washed in water — 
a, convoluted portion of the nrini- 
ferous tube; &, portion of a tube 
stripped of its epithelium ; e, outline 
of tube and crumpled capillaries 
having a fibrous appearance, the 
so-called matrix; d^ very small 
Malpighian body. Loops of vessels 
shrunk, showing cells in their 
walls. 

44. Renal epithelium— a, altered by acetic 

acid. 



46. Epithelium from the pelvis of the 
kidney. 

46. Epithelium from the ureter. 

47. Section of cortical portion of a healthy 

kidney washed in water and exam- 
ined in the same medium. The 
capillaries are not injected, and, 
being collapsed and shrunken, ex- 
hibit the fibrous appearance which 
is considered to be caused by the 
matrix. 

48. Section of another part of the same 

kidney, in which the vessels were 
injected. The nuclei on their coats 
are seen, but no fibrous matrix is 
distinguishable. 



Plate X., p. 68. 



49. Capillaries of Malpighian body injected 

with Prussian blue fluid, showing 
nuclei connected with their walls— 
a, a few coils separated from the 
rest of the tuft; b, part of a loop 
somewhat compressed; c, tissue 
which connects the coils with each 
other; ^ a small portion of a ca- 
piU^y compressed as much as pos- 
sible, showing the thickness of the 
capillary wall at the point of redu- 
plication. 

50. Casts of the nriniferous tubes from a 



case of acute suppurative nephritis. 
Casts formed in the convoluted part 
of the tube are seen embedded in 
material which has coagulated in 
the straight portion. 

51 . Casts from a case of acute suppurative 

nephritis. 

52. A portion of one of the casts much 

more highly magnified, showing 
bodies like white blood-corpuscles 
multiplying in the central part. 

53. White blood-corpuscles distending the 

capillaries of the kidney. 



EXPLANATION OF THE PLATES. 



Fig. 

64. Urea crystallised. 

65. Nitrate of urea. 
56. Oxalate of urea. 
67. Uric acid. 



Platb XI., p. 



Fig. 

68. Hippnricacid. 

69. Creatine. 
60. Inosite. 



PlATB XII., p. 160. 



61. Chloride of sodiam. 

62. Triple or ammoniaco-magnesian phos- 

phate. 

63. C^stals of indigo — a, obtained by 

sublimation; 6, larger crystals; c, 
small crystals in fluid. 

64. Uroglaucine from urine— a, small 



masses of fhe colour of pale Pms- 
sian blue ; 6, darker mass composed 
of small spherical bodies; c, crys- 
tals of uroglaucine of a deep purple 
colour. 
66. Chloride of ammonium crystallised. 



Plate XIII., p. 222. 



66. Diabetic sugar crystallised from urine. 
66*. Sporules and thallus of the yeast 
fungus, after Dr. HassalL 



7. Arrangement for estimating sugar by 

the polarising saccharimeter. 

8. Apparatus for estimating the quantity 

of sugar by fermentation. 



Plate XIV., p. 264. 



69. Leucine— a, crystallised from water; 

the rest from an alcoholic solution. 

70. Crystals of leucine. 



71. Crystals of tyrosine, firom a solution 

in boiling water. 
71*. Cystine from urine. 



Plate XV., p. 300. 



72. Chyle-corpuscles and molecular base 

from chylous urine. 

73. a, Sporules of fungi; 6, vibriones. 

74. Sporules of penicilium glaucum 

growing. 



75. Sporules of yeast ftmgus, covered with 

minute crystals of oxalate of lime. 

76. Different forms of bladder epithelium. 

77. Vaginal epithelium. 

78. Vaginal epithelium. 



80. 



Plate XVI., p. 302. 



Cast or mould composed of epithe- 
lium from the vagina, from a 
preparation in the possession of 
Dr. Tilt. 

Casts from the seminal tubules, one 
containing a great number of sper- 



matozoa. From the nrine of a 
healthy man 80 years of age. 
, Spermatozoa. 
Fungi in nrine, some of the forms 
very like spermatozoa. 



Plate XVIL, p. 308. 



83. Casts consisting of mucus from the 

straight portion of the uriniferous 
tubes. 

84. A mucus cast frx)m the straight por- 

tion of the uriniferous tube from a 
case of renal irritation. A spiral 
coil of mucus is seen upon the 
surface. 



85. Mucus from healthy urine. 

86. Large transparent waxy cast The 

other figures represent casts which 
have received a fresh deposit upon 
their exterior. 



EXPLANATION OF THE PLATES. 



XXIU 



Plate XVIII., p. 312. 



.Fig. 

87. Casts, some vith epiihelinin. Two 

very dark coloured, from the pre- 
sence of urate of soda. 

88. Small granular casts from a case of 

chronic nephritifl. 



Fig. 

89. Casts containing blood. 

90. Casts containing oil-cellB filled with 

oil. 

91. Large and small waxy casts. 



Plate XIX., p. 322. 



93. Urate of soda firom the scum of eva- 
porated urine in health. 

93. Pus-corpuscles fi^m the urine. 

94. The same acted upon by acetic acid. 

To the right are corpuscles more 
highly magnified. 

95. Pus-corpuscles altered by remaining 

in the urine. 

96. The same acted upon by acetic acid. 

97. Pus-corpnscles. the germinal matter 

of which is forming protrusions or 



outgrowths. When detached these 
may grow into new corpuscles. 

98. Formation of pus from the germinal 

matter of vaginal epithelium. 

98*.Crystal8 of triple phosphate and small 

globules of earthy phosphate. 

99. Pus-corpuscles forming outgrowths. 
100. Cells of bladder epithelium— a, fi*om 

the fundus; b, near the orifice of 
the ureter ; e, from the neck of the 
bladder. 



Plate XX., p. 



101. Phosphate of lime in the form of 

dumb-bells from the mucus of the 
gall bladder. 

102. Dumb-bells of phosphate of lime 

from the urine of a patient suffer- 
ing from continued fever. 



103. Little angular particles of phosphate 

of lime. 

104. Phosphate of lime in a crystalline 

form. 

105. Uric acid. 

106. Various forms of uric acid. 



Plate XXI., p. 344. 



107. Octohedra and dumb-bells of oxalate 

of lime. In the crystal marked a 
the edges are directed towards the 
observer. 

108. Octohedra of oxalate of lime. 

109. Prismatic crystal of oxalate of lime. 

110. Very perfect dumb-bells of oxalate 

of lime from the urine of a child 
sufi'ering from jaundice under two 
years of age. 

111. Blood-corpuscles, a, b, c, taken from 

the living body; d, «, /, from the 



urine; d, corpuscles smaller than 
natural; at e, their circumference 
serrate and ragged ; at /, a some- 
what similar appearance. 

112. Dumb-bells of oxalate of lime. The 

crystalline material has been al- 
most entirely dissolved away from 
the organic matter in which it was 
deposited. The appearance of a 
cell-wall is produced. 

113. Sporules of fungi resembling blood- 

corpuscles from acid urine. 



Plate XXII., p. 364. 



114. Cells from the urine of a case of 

acute rheumatism — a, in the na- 
tural state; 6, treated with acetic 
acid; c, cells resembling pus; rf, 
the same treated with acetic acid. 
The small circular bodies are blood- 
corpuscles. 

115. Large cells filled with granular mat- 

ter in the urine of a case of chronic 
bronchitis. 

116. Cell found in the urine of a case of 

renal dropsy. 

1 17. Menstrual finid from a case of im- 

perforate hymen. 



118. Sarcinse, &c, in vomit— a, sarcinse; 

b, altered starch; e, sporules of 
fungi; d, vibriones; e, oil-globules; 
/, starch globule from bread, 
cracked. 

119. Cancer •'cells'* from the urine of a 

patient suffering from cancer of 
the bladder. 
1 2a " Cell " of normal bladder epithelium 
undergoing division. Growth takes 
place in the same manner as in 
the case of the cancer, but more 
slowly. 



XXIV 



EXPLANATION OF THE PLATES. 



Plate XXIII., p. 380. 



Fig. Fig. 

121. Echlnococci. 

1 22. Diplosoma crenata ( Asthuk Fasbe) , 

half the natural size. 

123. Booklets of echinococci. 125. 

124. A microscopic oxalate of lime cal- 

culus formed fi:om a collection of 
dumb-bells. Portions of some 126. 
dumb-bells are seen on its external 



surfiEuse. a, a much smaller cal- 
culus consisting of two dumb- ' 
bells. 

Small collection of dumb-bells sucli 
as often forms the nucleus of a 
calculus. 

Small globules and octohedra of 
oxalate of lima 



Plate XXIV., p. 384. 



127. Uiic acid calculus deposited upon a 

smaller calculus consisting of ox- 
alate of lime. 

128. Mulberry calculus weighing twelve 

drachms. Two-thirds of the na- 
tural siz& From a photograph. 

129. Mulberry calculus of a dark plum 

colour. Half the natural size. 
From a preparation in the Oxford 
Museum. 

130. Calculus consisting principally of 



triple phosphate deposited upon a 
uric acid calculus. 

131. Oxalate of lime calculus of a brown 

colour. Its surface was very un- 
even. Half the natural size. 

132. Calculus composed of phosphate of 

lime, with a calculus in the centre 
consisting of uric acid and oxalate 
of lime. 

133. Small prostatic calculi. Natural 

size. 



ORIGINAL ANALYSES OF URINE. 



Page 

1. Hydruria 146 

2. Urine containing excess of urea 156 
3, 4. Eczema 

5. Eczema in a boy, age 18 

6. Icthyosis in a girl, age 15 

7. Chorea in a girl, age 10. . . . 170 

8. „ in a girl, age 12.. 

9. „ in a girl, age 14.. 

10. „ in a girl .. 

11. „ in a boy, age 10.. 

12. „ in a boy, age 14.. 

13. Pneumonia— 4th day of the disease 173 

14. „ 5th day „ „ 

15. „ 6th day „ „ 

16. „ 10th day „ „ 

17. „ 22nd day „ 

18. Elephantiasis Grsecorum 

19. M „ 

20. Hysterical Coma . . 

21. Paralysis of the insane . . 

22. „ ,. .. 

23. „ „ .. 

24. „ „ .. 

25. Acute mania with paroxysms 

26. „ „ 
27. 

29. Chronic Inflammation of brain 184 

30. tt »» ft 

31. „ 

32. Epilepsy: fits every 6 or 10 minutes „ 

33. M same patient .. .. „ 

34. t, „ .. •• » 

35. „ from an intemperate man „ 

36. w ^om a man with slight 
general paralysis . . . . „ 

37. Delirium tremens .. .. 185 



181 
♦» 
182 



Puerperal mania . . 

Phosphate— urine in health. Im- 
mediately after dinner 

Ditto— ditto after three hours' 
reading 

Ditto— ditto before dinner 

Ditto— ditto four hours after 
dinner 

Urine mollities ossium . . 



Albuminous urine 

Urine containing sugar and aJ- 
bumen 

Ditto ditto 

Diabetic urine from a girl, age 19 
ff i» >« 

„ from a man, age 30 
„ from a woman , age 28 
„ from a patient pass- 
ing 60 ounces in 24 hours . . 

Ditto from a girl, age 18 



Chylous urine, containing 13*9 

grains of fat per 1000 
Urine from the same case, no fat 
Chylous urine 



Page 
185 



186 

188 
II 

199 

220 

252 

253 

11 

254 



272 
273 



62. „ byDr. BEifCB JoNBs 276 

63. 

64. „ ^7 Dr- Baker Edwards 277 

65. Urine containing sarcine . . 299 
Smegma Preputii . . 300 

66. „ „ deposit of urates 317 

67. „ „ cystine .. ..355 

68. „ „ II .. .• «i 

69. „ „ „ .. .. 856 



CHAPTER I. 



Tests. — Chemical Apparatus and Instruments necessary for 
THE Clinical Examination of Urine. Balance — Weights^ 
Test'tubes — Test-tube Holder — Small Retort Stand — Tri- 
pods and Wire Triangles — Spirit-lamp — Platinum Cap- 
sules — Water-hath — Beakers — Conical Glasses — Evapo- 
rating-basins — Wash-bottle — Glass Funnels — Filtering- 
paper — Glass Measures — Stirring-rods — Test-papers — 
Thermometer — Bloivpipe— Pipettes — Urinometers and Spe- 
cific Gravity Bottles — Clinical Pocket Microscope — Object 
Glasses — Microscope Lamp — Glass Slides — Thin Glass — 
Watch Glasses — Glass Cells — Brass Forceps — Stage Mi- 
crometer — Neutral-tint Glass Reflector — Bottles^ with capil- 
lary orifices. 

Fob the general clinical investigation of urine, the practitioner 
requires certain tests and apparatus for performing chemical analysis, 
and instruments for examining urinary deposits by the microscope. 
I purpose, in the present chapter, to refer briefly to those instru- 
ments and pieces of apparatus I have found most necessary, inex- 
pensive, and useful. These can be readily obtained of most instru- 
ment makers. 

Tests Aim Chemical Apparatus. 

1. Tests.— The principal reagents required for qualitative and 
quantitative analysis of the urine are enumerated below. They 
should be kept in stoppered bottles, of from two to four ounces' 
capacity. The strength of the solution required varies somewhat in 
different test solutions ; but from ten to fifty grains of the salts may 
be dissolved in each ounce of distilled water. Distilled water 



2 TESTS. 

should be kept in a quart bottle ; and it will be convenient to keep 

one of the wash-bottles represented in Fig. 10, Plate II., also filled 

with distilled water. 

strength. 

Aleohol . . ROyC*KHi 8p. gr. 0-83 

STxlphnrio Add H0,S03 Sp. gr. 1-84 

Hydrochloric Acid HCl Sp.gr. 1-20 

Hltric Add ^ HO,NOs Sp.gr. 1-20 

Oxalic Add CW.HO 50 grs. to 1 oz. 

Acetic Add ^ . . HOjC^H^yO^ FharxnacopoBia. 

Ammonia NBP Sp.gr. 0*88 

Oxalate of Ammonia .^ . . NH40,C^+ Aq 80 gn. to 1 oz. 

Potash KO - . . Sp.gr. 1060 

Eerrooyaiiide of Potassium E?,FeCy3 + 8Aq 25 grs. to 1 oz. 

Chloride of Ammonium . . NH^ 50 grs. to 1 oz. 

Lime Water Ca0,H0 ^ . . Sat. sol. 

Carbonate of Soda NaO,C034 lOAq 160 grs. to 1 oz. 

Phosphate of Soda 2HaO,HO,PO^ +24Aq. . 50 grs. to 1 oz. 

Chloride of Caldum CaCl 50 grs. to 1 oz. 

Chloride of Barium ...... Bad 50 grs. to 1 oz. 

Perchloride of Iron Ee^' 100 grs. to 1 oz. 

Sulphate of Copper CuO,S03+ Aq 50 grs. to 1 oz. 

Nitrate of Silver Ag0,N0^ 25 grs. to 1 oz. 

Bichloride of Mercury HgCl^ 25 grs. to 1 oz. 

Bichloride of Platinum . . FtCl^ Sold in solution. 

Fehling's Solution. — ^For mode of preparation, see § 47. 

2. Balance. — A very effident balance, which weighs to the 
l-50th of a grain, and bears 1,000 grains in each scale, and is 
adapted for the quantitative Examination of urine and other animal 
fluids and solids, may be obtained of Mr. Becker, of the firm of 
Elliott Brothers, Strand, for the sum of £Z, 

3. Weifirhts. — It is desirable to be provided with gramme, and 
also with grain weights. These are furnished with the scales. 

4. Test-tubes, of various sizes, will be required. The observer 
should also be furnished with the rack and drainer represented in 
Plate I., Fig. 1. 



CHEMICAL APPARATUS. 
Fig. 1. 



Pl,ATK 1. 




§§ 12, 23. 



To /lUX OOQf. '1. 



APPABATUS. 3 

5. Test-tube Holder.— A very siiQple form is represented in 
Plate II., Fig. 11. 

6. Small Betort Stand, as seen in Plate I., Fig. 2 ; or attached 
to the spirit-lamp, as in Fig. 4. 

7. Tripods and Wire Triangles, for supporting platinum cap- 
sules or foil, while the organic matter is being burned off. Plate I., 
Figs. 5, 8. 

8. Spirit-lamp. — The ordinary glass spirit-lamp is the most 
conyenient form. 

9. Small Platinum Capsule and Platinum Foil. — A capsule 
about two inches in diameter will be large enough. This can be pur- 
chased for 128, or 14^. It should be exposed to the clear smokeless 
flame of a spirit-lamp, or to that obtained by burning coal gas mixed 
with air, as it issues through fine wire gauze, or from a small conical 
tube placed over the gas-burner. Care must be taken that no lead 
or pewter comes into contact with the platinum when heated, or it 
will be instantly destroyed. 

10. Water-bath. — A very simple form of water-bath is repre- 
sented in Plate I., Fig. 3; or a small saucepan may be used. But 
when the observer desires to make many careful analyses of urine, 
he should be provided with a larger water-bath, so that four or five 
basins may be placed over it at one time. Several rings, of various 
sizes, cut out of thin sheet copper, will be required to support basins 
of different sizes over the water-bath. A little hot-water drying-oven 
is necessary for careful quantitative determinations. The injecting- 
can (" The Microscope in Medicine,''* page 25, fig. 59) may also be 
used as a water-bath. 

The porcelain basins with residues, which have been dried over 
the water-bath, should be allowed to cool before being weighed. The 
observer will find it useful to have two or three glass shades, about 
9 inches in diameter, with shallow glass dishes, for containing strong 
sulphuric acid, about four or five inches in diameter. Upon the glass 
dish, about half filled with the sulphuric acid, is placed a piece of wire 
gauze, or perforated zinc, to support the basins. In this manner the 
residues may be allowed to cool, without absorbing water, and they 
may be kept dry for some time, if requisite. 

B 2 



4 APPARATUS FOB 

11. Two or Three Nests of Beakers.* 

12. Conical Glasses, of the fonn represented in Plate I., Figs. 6, 
7, or in Plate II., Fig. 9. The former combines the glass for the 
urinometer with a conical glass for collecting urinary deposits. This 
is a most useful form of conical glass. It was devised by Dr. Budd. 

13. ForoelaizL Evaporatinff-basixis, of various sizes, from eight 
ounces to half an ounce capacity. 

14. Wash-bottle, for washing precipitates on filters (Plate II., 
Fig. 10). 

15. Glass Foxmels, of various sizes (Plate III., Eig. 13). 

16. Fllterixifir-paper, which can be purchased of the instrument 
makers, or of most stationers, under the name of white blotting- 
paper. The mode of folding filtering-papers is represented in Plate II., 
Fig. 12, or they may be purchased, ready cut in circles, of the opera- 
tive chemists. 

17. Glass Heasures. — One pint measure, one 4-ounce, one 1-ounce, 
1,000-grain measure, cubic inch measure. The cubic centimeter 
measures are described in Chapter II., on " The Volumetric Analysis 
of Unner 

18. Stirringr-rods.— These are made of ordinary glass rod, rounded 
at each end in the blowpipe flame; or of pieces of glass tube, 
the ends of which are drawn oflP and closed in the flame of the spirit- 
lamp or blowpipe. 

19. Test-papers. — Blue litmus and reddened litmus. 

20. Thermometer. 

21. Blowpipe.— An ordinary gas-fitter's blowpipe, which costs 
6d., answers every purpose. 

22. Pipettes, of two or three sizes (Plate IIL, Fig. 14a, b). 

* Glass and porcelain apparatus maj be obtained of Messrs. Powell, of the White- 
friars Glass Works, or they will be furnished by the inrtrument makers. 



CHEMiCAli AND MICROSCOPICAL APPARATUS. Platk II. 

Fig. 9. 

FJ^. 10. 





*l-i 



• 12. 




§ }H. 



To jace i>u.«K \. 



CHEMICAL EXAMINATION. O 

28. TTrinometers — Specific Gravity Bottles, for taking the spe- 
cific gravity of urine. The specific gravity of a fluid is obtained 
most correctly by ascertaining the weight of equal bulks of the fluid 
to be examined, and distilled water. For this purpose, a small 
bottle, with a tubular stopper, holding exactly 1,000 or 500 grains of 
distilled water, at a temperature of 60", is the most convenient form 
of apparatus (Plate III., Fig. 16). All that is necessary is to fill the 
bottle carefully with the urine, wipe it dry, and then weigh it, aft^ 
having counterpoised the bottle. The number of grains which the 
fluid weighs is the specific gravity in the case of the 1,000-grain 
bottle, double the weight for the 500-grain bottle, four times the 
weight for a bottle holding 250 grains, and so on, in like proportion. 

This method, although perfectly exact, and readily performed 
where a good balance is at hand, is nevertheless too tedious and 
troublesome for the practitioner in a general way, and, in the sick- 
wards, a much simpler, though less correct method, is usually 
resorted to. The specific gravity is obtained by a small hydrometer, 
usually termed a urinometer. The form of this instrument, and the 
mode of using it, are well known ; but there are one or two points 
in its construction and management which it may be well for me to 
refer to. As sold, these instruments are often nearly useless, in 
consequence of the carelessness displayed in their manufacture. Out 
of twenty instruments, I have found several differing as much as 
ten degrees from each other. If the stem of many urinometers be 
examined, it will be found that all the degrees marked upon it are 
equal, which clearly ought not to be the case (Plate III., Fig. 15a); 
for when fluids of low specific gravity are operated on, a very small 
portion of the stem remains above the surface of the liquid (Plate I., 
Fig. 66), while the reverse holds with respect to liquids of great 
density. In the latter case, there is, of course, a much greater weight 
of stem above the liquid, tending to force the instrument lower in 
the fluid than in the former (Plate I., Fig. 6a). Allowance must also 
be made for the fact that the fluid becomes denser as we pass from 
the upper to the lower strata.* The tendency of the instrument to 
indicate a higher density than the real one, renders it necessary that 
the degrees should decrease in length from the upper towards the 
lower part of the steuL The practitioner should carefully examine 

• This error has been corrected hy Mr. Ackland, of Messrs. Home and Thorn- 
thwaite's, where accurately graduated instruments may be obtained. 



6 APPARATUS FOR 

his urinometer, to see that there is this difference in the degreesr 
(Plate III., Fig. 15ft), and if not, it should be changed. I strongly 
recommend everyone to test the urinometer by immersing it in 
fluids, the speciflc gravity of which has been ascertained by the 
bottle, or by a well made and previously corrected urinometer. If 
the degrees are incorrect, the observer can always bear in mind the 
amount of error, and allow for it in taking the specific gravity of 
different specimens of urine. The vessel which is employed for 
receiving the urinometer should not be too narrow, in case the bulb 
should rub against the sides, when it becomes difficult to ascertain 
the real density. Its diameter should be rather more than a quarter 
of an inch over that of the widest part of the bulb of the urinometer. 
The glass delineated in Plate I., Fig. 6, is a very convenient form. 

Another method of taking the specific gravity, which is sometimes 
followed, consists in having a number of small glass bulbs, with the 
density of the fluids in which they neither sink nor swim marked 
upon them. By placing one after another in the urine, one is found 
which remains just beneath the surface, and the number upon it 
indicates the specific gravity of the fluid. 

»% The chemical apparatus required for the analysis of urine will be 
provided by Messrs. Bullock & Reynolds, 3, Hanover Street, W.; Messrs. 
GriflSn, Bunhill Row, RC; and other Operative Chemists; or they will be 
procured for the practitioner by most of the Instrument Makers. 

Apparatus required for the Mioroscopioal Examinatioit 
OP Uriwary Deposits. 

24. Clinical Pocket Microscope.— This is a very simple and 
inexpensive instrument, which I have lately arranged for the micros- 
copic examination of urinary deposits and other substances. It may 
be used as a field microscope, and will be found a most useful form 
of instrument for the practitioner. When closed, it is only six inches 
in length, but when arranged for examination, the tube is drawn out 
as long as that in the ordinary microscope. Any powers can be 
adapted to it; and direct light, or light reflected from a mirror, may 
be employed. I have now used this instrument for some time for 
teaching in the wards, and find that it answers its purpose well. It 
may be fitted up with mirror, pipettes, slides and cells, in a leathern 
case. The instrument is made by Mr. Highley, 70, Dean Street; 



CHEMICAL AND MICROSCOPICAIj APPARATUS. Plate III. 

Fig. 17. 



Fig. 13 




MICBOSCOPICAL EXAMINATION. 7 

Messrs. Powell <fe Lealand, 170, Euston Road; Mr. Salmon, 100, 
Fendmrch Street ; and by Mr. Matthews, Portugal Street, Lincoln's 
Inn, The clinical microscope is represented in Plate III., Fig. 17. 
It costs, with the eye-piece, but without object glasses, 258. The 
arrangement of the spring, by which the preparation is kept in 
contact with the stage, while every part of the field is examined, is 
represented in Fig. 19. I have had this instrument fitted to a small 
stand, with a lamp for use by night, and a mirror for day, so that it 
can be very easily handed round in a lecture-room. I find this 
arrangement most convenient for demonstrating objects to large 
classes. The stand, with the clinical microscope, is represented in 
Plate III., Fig. 18. It is convenient also to be provided with a 
simple student's microscope, with large stage. (See the " Microscope 
in Medicine^) The tube of an ordinary microscope can easily be 
made moveable and fitted with the end tube and stage of the clinical 
microscope — a plan which has been carried out by Mr. Highley. 

26. Object-srlasses reatdred. — The qtuirter of an inch, magni- 
fying about 200 diameters, and the inch, magnifying from 30 to 50 
diameters, are the two most useful object-glasses for the purposes of 
the medical practitioner. The best English objective costs about £5, 
but good powers may be obtained for about SOs, 

26. 3tticro8cope liamp.— An ordinary French lamp affords a 
very excellent artificial light, especially if provided with a blue 
glass chimney. The best form of gas lamp has been arranged by 
Mr. Highley, of 70, Dean Street, Soho Square. This lamp is figured 
in Plate IV., Fig. 20. 

27. Glass Slides— the only slides used— should be three inches 
long by one inch broad. They may be purchased, at from 28, to 6^. 
per gross, of Messrs. Claudet and Houghton, 89, High Holbom, E.C., 
and of most instrument makers. 

28. Thin Glass, cut into squares and circles. This may be 
obtained of the various instrument makers, and of Messrs. Claudet 
and Houghton. 

29. Watch Glasses, of various sizes. Watch glasses are very 
convenient for evaporating small quantities of fluids. The common 
glasses are those which are required. They cost Is, per dozen. 



8 APPARATUS FOR 

30. Glass Oells, for examining urinary deposits. A simple form 
of cell is represented in Plate V., Fig. 25, but I have found the so- 
called "animalcule cages" most convenient instruments for the 
examination of urinary deposits. The best form is represented in 
Plate v., Fig. 24, which is supplied by Messrs. Powell and Lealand. 
Fig. 26 is a section of a smaller one, which can be used with the 
clinical microscope. 

81. Brass Forceps, supplied by the microscope makers. 

82. Stagre Micrometer, divided into lOOths and l,O00ths of an 
inch. This is required for measuring objects, according to the plan 
described in " The Microscope in Medicine" pp. 41—45. A scale, 
divided to l,000ths of an inch, and magnified 215 diameters, is repre- 
sented in Plate V., Fig. 23. 

88. Neutral-tint Glass Beflector, for tracing the outline of 
objects (Plate V., Fig. 22). It is very important that the observer 
should be familiar with the methods of drawing and measuring 
objects accurately. The arrangement of the microscope for tracing 
the outline of objects, with the aid of the neutral-tint glass reflector, 
is represented in Plate IV., Fig. 21; see also, ^The Microscope in 
Medicine,'' p. 33. 

84. Bottles with Capillary Orifices. — These bottles are most 
convenient for testing minute quantities. Different forms are repre- 
sented in Plate V., Figs. 28, 30. They may be obtained separately, 
in boxes containing 6 or 12 (Fig. 27); or fitted up in a box, witiii 
other apparatus required for testing urinary deposits and calGoli 
(Plate II., Fig. 11). 

These bottles are filled as follows: — A little distilled water k* [ 
poured into a small porcelain basin, the tube being inverted so thai 2 . 
the orifice dips beneath the surface of the water. Heat being nd#* 
applied to the bottle, by means of a spirit-lamp, the air in ih# 
interior is expanded, and partially expelled. As the bottle becoDMi 
cool, a certain quantity of the fluid rises up into its interior. A fyw^ 
drops having been introduced in this manner, the bottle is held in' 
the test-tube holder over the spirit-lamp; and, when the water. boik^ 
and the greater part has been converted into steam, the orifloe is - ' 
quickly plunged a short distance beneath the surface of the liquid; 



MICROSCOPICAL APPARATUS. 
Fig. 20. 



PLATE IV. 




To fact page ^ 



MICROSCOPICAL APPARATUS. Plate V. 

Fig. 22. Fig. 23. Fig. 24. 




0" 




G 




§33. 



X 215 §§ 30, 58. 



Sooo TUoo 

§32. 





Fig. 25. 



























§ 30, 58. 



Fig. 27. 



Fig. 26. 

4^ 



§§ 30, 58. 



^ 



Fi^. 28. 




§34. 




MICROSCOPICAL EXAMINATION. 9 

to be introduced, wMch has been already placed in another small 
porcelain capsule. As the steam condenses, the solution will, of 
course, rise up, and would completely fill the little bottle, if it were 
maintained in this position, but, when about three parts full, it is to 
be removed. If completely filled, it would be difficult to expel a 
drop, when required. A certain quantity of air, therefore, is allowed 
to remain within the bottle; this being expanded by the warmth of 
the hand, the quantity of fluid required is forced out. For micro- 
scopical purposes, these little bottles possess many advantages over 
the ordinary stoppered bottles. In the first place, a most minute 
quantity of the test can be obtained, and this can be carefully 
regulated. Secondly, there is no danger of the reagent being spoilt by 
the introduction of various foreign substances from without. If an 
ordinary stoppered bottle be used, a drop of fluid is generally removed 
with a pipette, or stirring-rod; but if these should not be quite clean) 
foreign substances may be introduced, and the reagent spoilt for 
further operations. Carelessness upon this head will lead to the greatest 
inconvenience, and may be productive of the most serious mistakes. 
Thirdly, testing by means of these little bottles can be conducted in 
a very short space of time; and all the tests required, even for a 
very complete qualitative examination, can be packed in a very 
small compass. 

A useM form of pipette, which can be adapted to ordinary 
bottles, in the form of a stopper, is represented in Plate V., Fig. 34. 
The tube is very narrow near the end (c), so that a very small drop 
can be obtained. A piece of India-rubber is stretched over the 
other extremity, and by slightly pressing this a drop is expelled. 
This plan is recommended by Dr. Lawrence Smith, of Louisiana. 

All the necessary apparatus required for the ordinary qualita- 
tive examination of urine, with tests, in bottles with capillary 
orifices, and apparatus necessary for the microscopical examination 
of urine, have been arranged in a little case, as represented in 
Plate II., Fig. 11. This can be purchased of Mr. Highley. 

«\ The microscopical apparatus required for the examination of urimiry 
deposits may be obtained of Mr. Baker, Holbom; Mr. Highley, 70, Dean 
Street, W.; Mr. Matthews, Portugal Street, Lincoln^s Inn; or it will be 
procured for the practitioner by the instrument makers. 



B 3 



10 



CHAPTEE 11. 



The Volumetric Process of Analysis for estimating some 
OF THE Constituents of Urine. Apparatus required. 
Burettes — Pipettes — Cylindrical Glass Measure — Beakers 
and other Apparattcs — Weights and Measures — On the 
Estimation of Urea and Chlorides ; Determination of the 
Urea; Preparation of the Solution; Performance of the 
Analysis — Determination of the Chloride of Sodium; Pre' 
paration of the Solution ; Performance of the Analysis — 
Estimation of Phosphoric Acid; Preparation of the Solu- 
tion; Performance of the Analysis — Determination of the 
Sulphuric Add; Preparation of the Solution; Performance 
of the Analysis — Determination of the Sugar; Performance 
of the Analysis — 2)r* Davy's Method of Determining Urea, 

Although the general processes adopted for the estimation of 
the various constituents might be systematically arranged under 
their respective heads, it has been thought more convenient to treat 
of the subject of volumetric analysis in one chapter. 

The ordinary methods for determining the proportion of the 
most important constituents in the urine possess many defects. 
Chemists have long found that the results are inaccurate, and not to 
be depended upon at all, unless great care has been taken in the 
process of analysis ; while, at the same time, they are very laborious, 
and require an amount of chemical skill which few possess, unless 
they have been in the habit of working for some time in a laboratory. 
Practitioners have for years past recognised the importance, in many 
cases, of being acquainted with the amount of the urinary con- 
stituents removed from the body in twenty-four hours, and have 
desired to know how these proportions are affected by certain physi- 
ological conditions of the system, or by the administration of 



VOLUMETRIC ANALYSIS. 11 

remedies, or by disease. Till within the last few years, the greatest 
practical difficulties existed with reference to carrying out such 
researches. The physician was not chemist enough to undertake 
them; and the pure chemist, not having sufficient knowledge of 
medicine to enable him to see the use of such inquiries, was not 
interested in the matter. In practice, it will, I think, be found that 
all such investigations, if they are to be of any real use, must be 
carried on by a physician who at the same time is acquainted with 
chemistry. Within the last few years, the process of volumetric 
analysis has been introduced, principally by Professor Liebig, to 
whom we are entirely indebted for the excellent and accurate plan 
of estimating the urea and chloride of sodium. Physicians may 
now, with very little practice, carry on these researches; and when 
a sufficient number of observations have been made in various cases 
of disease, very important facts will, no doubt, be elicited. These 
processes are not free from error ; but they are sufficiently accurate 
for all the requirements of the physician who desires to know the 
relative variation of the principal substances in different cases, rather 
than to determine the exact quantity present in a given specimen of 
urine. The volumetric process is, at least, as accurate as the old 
plans; and if it be carefully carried out, with attention to certain 
points of detail, much more so. In cases in which very accurate 
results are required, I must refer the reader to Neubauer and Vogel's 
treatise on the urine, where rules for all the corrections are given ; 
but, for all ordinary purposes, the plan recommended below has been 
found in practice sufficiently exact. The directions here given were 
obtained after performing the different processes several times, and 
were arranged by my friend and former assistant. Dr. Von Bose, 
whose original paper on the subject was published in the "Archives 
of Medicine," Vol. I. 

The principle of volumetric analysis is based upon the fact, that sub- 
stances combine in definite and equivalent proportions. If, therefore, 
we accurately measure the proportion of the test required to combine 
with the whole of the substance present in a solution, a simple calcu- 
lation, according to the chemical equivalents of the two bodies, will 
enable us to obtain the desired result For instance, suppose the quan- 
tity of sulphuric acid (SO*) in a solution is to be determined. We know 
that to precipitate 40 parts of sulphuric acid, exactly 122 parts of 
crystallised chloride of barium (Ba CI + 2 HO) are required,— or for 1 



12 APPARATUS FOB 

part of sulphuric acid, 3*06 parts of chloride of barium, — or for •01 
gramme ='154 grain of sulphuric acid, '0305 gr.='747 gr. of chloride 
of barium. Now, if we dissolve 30*5 gr.=471'04 grs. of chloride of 
barium, in 1,000 cubic centimeters of water =15,444 grs., or about 
If pint, every cub. cent, contains '0305 gr.='47 gra of chloride of 
barium; and if we place this solution in a tube, graduated to cubic 
centimeters or grains, and allow it to flow gradually into a solution 
of sulphuric acid as long as we get a precipitate, the number of cub. 
cents, used indicates the quantity of chloride of barium employed; 
and from these data we at once ascertain the proportion of sulphuric 
acid contained in the solution. 

Apparatus ebquired fob Volumetbio Analysis. 

85. Burettes or Graduated Tubes (Plate YI., Fig. 31^. — It 
is convenient to be provided with one or more holding 50 cub. cents., 
and graduated to half cub. cents. The lower part of the tube is 
drawn to a small calibre; and to its extremity a small piece of glass 
tube, about two inches long, is connected by a piece of India-rubber 
tube,/, so arranged that it can be compressed at pleasure by a wire- 
spring, just below /, as represented in the figure. When the two 
extremities of this spring are pressed by the finger and thumb, fluid 
will flow down the tube; and when the pressure is removed, the tube 
is rendered impervious. This little apparatus serves the part of a 
stop-cock, and possesses many advantages over the latter. Care must 
be taken to keep the tube perfectly clean, and the India-rubber 
should be well washed after every analysis. The apparatus required 
for the volumetric method of analysis is represented in Plate VI., 
Figs. 31, 32. a, is a glass jar, capable of holding 500 C.C., graduated 
to 5 C.C. by a pipette, graduated to hold 20 C.C. c, a piece of 
India-rubber tube for the convenience of allowing the fluid to escape 
very slowly when pressure is applied by the finger and thumb, rf, is 
the burette, which is capable of holding 50 CO., and graduated to 
half C.C. The numbers are not marked on the tubes in the figure. 
e, Cy are small pieces of wide India-rubber tube to hold the burette in 
its place. /, a small piece of India-rubber tube connecting the 
extremity of the burette with the spout, and capable of being com- 
pressed by the spring, the form of which is represented at g. The 
mode of using the apparatus is also seen in this figure. 



CHEMICAL AND MICROSCOPICAL APPARATUS. Plate V[. 

Fi.^. 31. 

i'ig. 32. ;i 




Fig. 33. 



§35. 



n 



1 



§35. 



Fig. 34. 




§58 



To face page 12. 



VOLUMETRIC ANALYSIS. 13 

The pipette is figured at J, Fig. 31. It is convenient to be 
furnished with one of 20 CO. =308*88 grs. capacity, one of 16 C.C. 
= 231 '66 grs., and one of 10 C.C. = 154-44 grs. The Cylindrical Glass 
Measure, graduated to 500 CO., is represented at a. 

The little apparatus represented in Plate VI., Fig. 32, was con- 
structed by me, for the purpose of filtering a little of the fluid from 
the deposit, in order to see if all the substance was precipitated. 
Filtering-paper is tied round the lower extremity, a. By plunging 
this beneath the fluid, the solution rises quite clear in the interior, 
and may be poured through the spout, J, into a small test-tube kept 
for the purpose. The drawing represents the tube half the real size. 
In estimating the quantity of sugar, this little apparatus will be 
found very convenient. 

Beakers, stirring-rods, test-paper, funnels, and porcelain basins, 
with a tripod or small retort-stand, with a spirit-lamp or gas-lamp 
and small sand-bath, are also required.* 

The test-solution is poured into the burette at the top till it is 
nearly full. A beaker is then placed beneath the orifice, and a 
certain quantity of fluid allowed to flow from the tube until the 
upper surface reaches zero on the scale. The line on the burette 
should always correspond to the lowest part of the thick line at the 
top of the fluid, caused by the capillary attraction of the walls of the 
tube. Care must be taken that the part of the tube below the India- 
rubber joint is also quite full of fluid. 

It is desirable that the pipettes should be provided at their upper 
extremity with a short piece of India-rubber tube, c, Fig. 31, as, by 
properly-applied pressure upon this with the finger and thumb the 
fluid may be allowed to escape very gradually. 

86. Weiglits and KCeasnres. — In these directions, weights are 
expressed in grammes and grains, and measures in cubic centimeters 
and grains, so that the observer may adopt either as a standard of 
comparison. Tubes graduated to grains can easily be obtained, if 
required. The grammes, gr., and cubic centimeters, CO., being 
always placed before the grains, grs. Thus, '01 gr. = *154 grs. is to 
be dissolved in 10 C.C. = 154 grs. of water. 



* The apparatus referred to may be obtained of Messrs. Bnllock and Reynolds, 
Hanover Street, Hanover Square, who also supply the test-solutions ready graduated ; 
and of Messrs. Griffin, Bunhill Row, E.G. 



14 VOLUMETRIC ANALYSIS. 

87. Estimation of Urea and Chlorides. — The determination of 
urea and chlorides is effected by solutions of penitrate of mercury 
(HgO.NO*). The principle upon which the method depends is this, 
that chlorine gives a soluble, and urea an insoluble, compound with 
peroxide of mercury (HgO), while chlorine has a greater affinity 
for mercury than urea has; therefore, if pemitrate of mercury 
(Hg.O.NO') be added to a solution containing chlorine and urea, the 
chlorine will first combine with the mercury, and no precipitate of 
urea and mercury will take place until all the chlorine has been 
saturated ; and if we observe how much of the solution has been 
used before a precipitate takes place, we can learn at once the 
quantity of chloride present. The volume of the solution required 
for completing the precipitation shows the proportion of urea, as will 
be explained presently. The same solution, however, is not used for 
both these determinations, as, for convenience in reckoning, it is 
better they should be of different strength. In both cases, it is 
necessary in the first instance to remove the phosphates from the 
urine. In order to effect this, a mixture of 1 volume of a cold 
saturated solution of nitrate of baryta (BaO.NO*) and 2 volumes of 
saturated baryta-water (BaO.HO) must be prepared. This is the 
Baryta-solution, 

Determinatioit op Ueea (CTI*N*0*). 

88. Preparation of the Solution. — If pure mercury is procured, 
71 '48 gr. = 1103*93 grs. are dissolved in pure nitric acid with the 
aid of the heat of a sand-bath. When fumes of nitrous acid (NO*) 
cease to be evolved, and a drop of the solution gives no precipitate 
with chloride of sodium (NaCl), it may be evaporated on a water- 
bath in the beaker in which it has been prepared, to the consistence 
of a syrup. It is to be diluted to make a volume of 1,000 C.C.= 
15444*00 grs. or about If pints; a few drops of nitric acid (NO') 
being added as often as the solution becomes turbid. In this way it 
will be made clear again. 

If the mercury of commerce is used, a somewhat larger quantity 
of it is treated with nitric acid as before, but the process is stopped 
before it is completely dissolved : it is allowed to cool, when crystals 
of protonitrate of mercury (HgjO.NO') will form. The crystals are 
thrown on a filter and washed with a little nitric acid. They are to 



ESTIMATION OF UREA. 15 

be boiled with nitric acid, till no more vapours of nl xous acid are 
given off, and no precipitate is produced if a little is dropped into a 
solution of chloride of sodium. By evaporating a solution to the 
consistence of a syrup, pure pemitrate of mercury (Hg.O.NO*) is 
obtained. This is diluted, but less water added than the solution 
will probably require. The proportion of mercury it contains is 
estimated either by sulphuretted hydrogen or by potash ; and lastly, 
it is diluted so as to contain '772 gr.= 11*92 grs. of peroxide of 
mercury (HgO) in 10 C.C.= 154*44 grs. 

1 CO. =15*44 grs. of this solution, made according to either of 
the above methods, indicates 0*01 gr. =0*154 gr. of urea. 

80. Ferformazioe of the Azial3rsiB. — In the first place, 40 C.G. 
=617-76 grs. of the urine are mixed with 20 O.C.= 308*88 gr& of 
the baryta solution: the precipitate is filtered, and 15 C.C. =231.66 
grs. of the filtrate are placed in a small beaker. These 15 C.C. con- 
tain 10 C.C. of urine. The burette is next filled with the solution, 
which is added as long as the precipitate is observed to increase. 
The following test is then applied, to ascertain if a sufficient quantity 
has been added. A drop of the mixture is removed with a glass rod 
and placed on a watch-glass. A drop of a solution of carbonate of 
soda (Na.O.CO*) is then placed near the first, and the two drops are 
allowed to flow together. If they give a white precipitate, the pro- 
cess is not yet finished ; more of the mercury solution must be added, 
and a drop tested as before, till the two drops, when they coalesce, 
give a yellow precipitate, which shows an excess of mercury. A 
second experiment may be made to confirm the first; and lastly, 
by reading off the number of the C.C. used, the quantity of uiea 
contained in the urine is immediately ascertained. Still there is a 
correction to be made: the first drops of the solution which pro- 
duced no precipitate did not combine with, and do not, therefore, 
correspond to, any of the urea present. This volume must be de- 
ducted, or about two cubic centimeters may always be subtracted 
from the volume of the test-solution used. 

Dbterminatiow of Chloride of Sodium (Na.Cl). 

40. Prepaxation of the Solution.— 17*06 gr. = 263*47 grs. of 
pure mercury are dissolved as before described, and the syrup diluted 
to a volume of 1,000 C.C. = 15444*00 grs.. or about If pints, as in the 



16 VOLUMETRIC ANALYSIS. 

''* ■ case. Or, the solution of pemitrate of mercury (HgO.NO*), 
made from the impure mercury, which has been analysed, is diluted 
in such proportion, that 10 C.C. of it may contain '184 gr.=2'84 grs. 
of peroxide of mercury (HgO). 

1 C.C. of this solution answers to '01 gr.=*154 gr. of chloride of 
sodium. 

41. Performajioe of the Analysis.— '40 C.C. =61776 grs. of 
urine are mixed, as before, with 20 C.C. =308-88 grs. of the baryta 
solution; 15 C.C. =231 '66 grs. of the filtered mixture are placed in 
a beaker and rendered acid by a few drops of nitric acid. The 
burette is filled with the test-solution, which is allowed to drop into 
the beaker, the mixture being continually stirred with a glass rod. 
As soon as the precipitate at first formed does not disappear by 
stirring, the operation is finished, and the volume of the solution 
used is read off. This shows the quantity of chloride of sodium 
contained in the urine. 

With regard to removing the phosphates, in both cases it is to 
be remarked that, if 1 part of the baryta solution to 2 parts of the 
urine should not precipitate the whole (a point easily ascertained by 
adding some of the baryta solution to a few drops of the filtered 
mixture), more of the baryta solution must be added. This then 
would somewhat modify the quantity of the mixture to be taken for 
the test. Suppose it is desired that it should still contain 10 C.C. = 
154-44 grs. of urine in it. 17i C.C. =270*27 grs. of the mixture 
would be required, if there were 3 parts of baryta solution to 4 parts 
of urine; 20 C.C. =308*88 gra would be taken if there were equal 
parts of baryta solution and urine. More than this will hardly ever 
be required. 

Estimation or Phosphoric Acid. 

The estimation of the phosphoric acid by this process is not so 
exact as those last described, and the greatest care must be taken. 
A solution of perchloride of iron is added, after the fluid to be tested 
has first been mixed with a solution of acetate of soda and free 
acetic acid. 

If perchloride of iron be added to a solution containing phos- 
phoric acid, a precipitate of phosphate of iron is produced; at the 
same time hydrochloric acid, which would redissolve the phosphate, 
is set free from the perchloride. In order to prevent this, acetate of 



PHOSPHORIC ACID. 17 

soda is added in the first instance ; the free hydrochloric acid decom- 
poses the acetate of soda, and acetic acid is set free, in which the 
phosphate of iron is insoluble. 

42. Freparation of the Sk>liitioii8. — 1. Solution of PercKLoride 
of Iron — 15*556 gr.= 240*24 grs. of pure iron wire are dissolved in 
pure hydrochloric acid, to which a little nitric acid has been added. 
The solution is evaporated to dryness on a water-bath, and the 
residue dissolved in water and diluted to 1,000 C.C. = 15,444 grs. 
Or a solution of perchloride of iron of moderate strength is prepared. 
The iron is estimated as peroxide by adding ammonia, and the 
solution is diluted so as to contain 1*556 gr.= 24*024 grs. of iron in 
100 C.C.= 1544*4 grs. In preparing this solution, care must be 
taken to avoid an excess of hydrochloric acid. One C.C. of this 
solution indicates '01 gr.=*154 grs. of phosphoric acid. 

2. Solution of Acetate of Soda and Acetic Acid, 20 gr.= 
308*88 grs. of crystallised acetate of soda, are dissolved in 100 C.C. 
=1544*4 gr. of water, and mixed with 100 C.C. =1544*4 grs. of 
acetic acid. 

3. Solution of Ferrocyanide of Potassium. 1 gr.= 15*44 grs, of 
ferrocyanide of potassium are dissolved in 100 C.C. =1544*4 grs. of 
water. 

43. Ferformazioe of the AnalyEds.— 100 C.C. =1544*4 grs. of 
the urine, are mixed with 10 C.C. =154*44 grs. of the solution of 
acetate of soda. The whole is divided into five parts — a, b, c, d, e — 
with a pipette, each part containing 20 C.C. =308*88 grs. of urine. 
The burette is filled with the iron solution, and into each of the 
parts half a C.C. more of the solution is dropped, beginning with 
six half C.C, so that 

a, J, c, dy e, contain 
6 7 8 9 10 half C.C. 

of the iron solution. They are left for 5 — 10 minutes, then 3 C.C. = 
46*3 grs. of each are filtered into five test-tubes kept ready ; and to 
the filtrates 1 C.C. =15*4 grs. of the solution of ferrocyanide of 
potassium is added. If in any of them the deep blue colour of 
Prussian blue appears, the analysis is finished, and the results may 
be confirmed by a second experiment. If the colour does not 
appear, five half C.C. more must be added to each of the parts, so that 



18 VOLUMETRIC ANALYSIS. 

a, by Cy d, e, now contain 

11 12 13 14 15 half CO.; 
and, after standing again, the same test is applied. This process 
must be repeated until the deep blue colour is obtained. The con- 
firmatory analysis is better made by taking 50 C.C.= 772*2 grs. of 
urine in each of five beakers, mixing the fluid in each of them with 
5 C.C.= 77*22 grs. of the acetate solution, and adding the propor- 
tional numbers of half CO., that are near those indicated by the 
first experiment. If, for instance, the colour appeared at 12 half 
CO., there must be added 28, 29, 30, 31, 32 half CO., to the different 
portions of the urine. 

44. Estimation of the Earthy Phosphates (Phosphate of 
Lime and Ma^gnesia). — The quantity of phosphoric acid combined 
with earths (earthy phosphates) may be determined as follows : — 
First, in one portion of the urine the whole amount of phosphwic 
acid is estimated as above; in another portion, the earthy phos- 
phates are precipitated by a little ammonia, and the phosphoric 
acid in combination with alkalies in the filtered fluid is volumetri- 
cally determined. The difference between both analyses indicates 
the quantity of phosphoric acid combined with the earths. 

If the urine to be tested is alkaline, and contains a deposit of 
earthy phosphates, the latter must first be dissolved in as little 
hydrochloric acid as will take it up. 

It is important to familiarise the eye with the tint of colour 
obtained; and care should be taken always to obtain the same tint. 

Determination op the Sulphuric Acid. 

46. Preparation of the Solution.— A quantity of crystallised 
chloride of barium is to be powdered, and dried between folds of 
blotting-paper. Of this, 30*6 gr. =471*04 grs. are to be dissolved in 
1,000 CO. =15444*00 of distilled water. 

A dilute solution of sulphate of soda is also required. 

46. Performance of the Analysis.— 100 CO. = 1544*4 grs. of 
the urine are poured into a beaker, a little hydrochloric acid added, 
and the whole placed on a small sand-bath, to which heat is applied. 
When the solution boils, the chloride of barium test is allowed to 
flow in very gradually as long as the precipitate is seen distinctly to 



ESTIMATION OF SUGAR. 19 

increase. The heat is removed, and the vessel allowed to stand still, 
so that the precipitate may subside. Another drop or two is then 
added, and so on, until the whole of the SO' is precipitated. Much 
time, however, is saved by using the little apparatus represented in 
Fig. 32. A little of the fluid is thus filtered clear, poured into a 
test-tube, and tested with a drop from the burette ; this is after- 
wards returned to the beaker, and more of the test solution added, 
if necessary. The operation is repeated until the precipitation is 
complete. In order to be sure that too much of the baryt^ssolution 
has not been added, a drop of the clear fluid is added to the solution 
of sulphate of soda placed in a test-tube. If no precipitate occurs, 
more chloride of barium must be added; if a slight cloudiness takes 
place, the analysis is finished ; but, if much precipitate is produced, 
too large a quantity of the test has been used, and the analysis must 
be repeated. 

For instance, suppose 27 half-cubic centimeters =208*47 grs. 
have been added, and there is still a slight cloudiness produced, 
which no longer appears after the addition of another half-cubic 
centimeter =7*722 grs. of the solution, we know that between 27 and 
28 half-cubic centimeters are required to precipitate the whole of 
the sulphuric acid present, and 100 C.C. = 1644*4 of urine contain 
between *135 and '14 gr.= 2*085 and 2*162 grs. of sulphuric acid, 

Detebminatioit of the Sugab. 

This method is deduced from the reaction occurring when Trom- 
mer's test is employed for testing for grape-sugar. It is well known 
that grape or diabetic sugar possesses the power of reducing the 
oxide of copper to the state of yellowish-red sub-oxide. 

47. Preparation of the Solution. — An alkaline solution of sul- 
phate of copper is prepared with the aid of tartaric add and potash. 
The former prevents the precipitation of the oxide of copper by the 
potash. 40 gr. = 617*76 grs. of crystallised sulphate of copper, are 
dissolved in about 160 C.C. =2471*04 of water. Next, 160 gr.= 
2471*04 grs. of neutral tartrate of potash, are to be dissolved in a 
little water, and from 600 to 700 gr., about 9,500 grs, of a solution 
of soda of 1*12 specific gravity, are to be mixed with it. The solu- 
tion of the sulphate of copper is added gradually, and the whole 



20 VOLUMETRIC ANALYSIS. 

diluted with water to a volume of 1154*4 C.C. = 17828'6 grs.; 
10 C.C.= 154*4 ^r». of this solution correspond to '05 gr.='772 grs. 
of sugar. 

48. Ferformanoe of the Azial3rsiB. — 10 C.C. = 154*4 grs. of the 
copper solution are diluted with 40 C.C.= 617*7 grs. of water, and 
placed in a porcelain dish. Ahout 20 C.C.= 308*8 grs. of the urine 
are diluted with from ten to twenty times their hulk of water, so as 
to produce, for instance, 300 C.C. =4633*2 grs. This is to be poured 
into the burette, and adjusted so as to fill it to the 0° of the scale. 
The dish with the copper solution is arranged on a sand-bath placed 
on a tripod stand, at a convenient distance beneath the orifice of the 
burette. A spirit or gas-lamp is applied until the copper solution 
approaches the boiling-point, when the urine is allowed to flow in 
gradually. The mixture is then boiled for an instant, and left for 
half an hour or more, when the suboxide will have subsided to the 
lower part. If, after the deposit has settled, the solution possesses a 
blue tinge, which is easily detected against the white porcelain, the 
analysis is not finished. More urine is to be added, and the mixture 
again boiled. This operation is to be repeated as long as any unre- 
duced oxide remains in solution. The process is finished when the 
supernatant fluid is colourless. The little filtering apparatus 
described in § 35, and figured in Plate VI., Fig. 32, may be used as 
soon as the solution is boiled ; and, if the whole of tKe copper has 
not been precipitated, the clear solution exhibits a blue tint. This 
saves time in performing the analysis. The proportion of sugar 
present in the urine is easily calculated. 

Suppose 24 C.C.= 370*6 grs, of the diluted urine have been 
required to reduce the 10 C.C. = 154*4 ^r«. of the copper solution, 
these 24 C.C. contain *05 gr. = -772 grs. of sugar. But since 300 CO. 
of the dilute solution contain only 20 C.C. =308*8 grs. of the urine, 
the 24 C.C. contain only 1*6 C.C.=24*7 grs. Therefore, 1*6 C.C.= 
24*7 grs, of urine contain '05 gr.= 0*772 grs, of sugar, or in 100 C.C. 
= 1,544 grs. of urine, 3*12 gr.= 48*18 grs, of sugar are present. 

»% The volumetric procesB of analysis of the urinary constituents is 
described at greater length in Neubauer and Vogel's " Analyse des Harris^* 
now being translated for the Sydenham Society; and in Dr. Thudichum's 
*' Treatise on the Pathology of the Urine,'*'* 



DAVY'S METHOD. 21 

40. Davy's Mode of determiniiiflr Urea. — A long stout glass 
tube, 12 or 14 inches in length, capable of holding two and a half 
cubic inches, is closed at one end, and ground perfectly smooth at 
the open extremity, and graduated to tenths and hundreds of a 
cubic inch. It is to be filled more than a thjrd full of mercury, and 
afterwards a measured quantity (from a quarter of a drachm to a 
drachm) of the urine poured in. Next, the tube is exactly filled 
with a solution of chlorinated soda (hypochlorite of soda, soda 
chlorinataB liquor, of the Dublin " Pharmaoopceia^^), Care must be 
taken to avoid adding too much of the solution, which must be 
poured in quickly. The orifice of the tube is instantly covered 
with the thumb; inverted once or twice, to mix the urine and 
hypochlorite ; and placed beneath a saturated solution of salt and 
water contained in a cup. The mercury flows out, and the solution 
of salt takes its place ; but, being more dense than the mixture of 
urine and hypochlorite, the latter always remains in the upper part 
of the tube. The urine is soon decomposed, bubbles of nitrogen 
escape, and collect in the upper part of the tube. When decom- 
position is complete, which is known by no more bubbles of gas 
being evolved, the volume collected is read off, and corrected for 
temperature and pressure. 

One-fifth of a grain of urea should furnish by calculation '3098 
parts of a cubic inch of nitrogen at 60" F. and 30' Bar. In one 
experiment. Dr. Davy obtained from the same quantity '3001 ; in 
another, -3069. 

Amount of Urea in an Ounce of Urine, as estimated by Dr, Davy, 
according to Liebig^s Method and his own. 

Liebig'8. Dr. Davy's. 

First experiment .. 3*680 3712 

Second experiment . . 5*328 5*472 

Third experiment 4*976 4*976 

i^^ Dublin Hospital Gazette^'' 1855, vol. L, p. 134; Braithwaite*s 

''Retrospects' 1854, vol. xxx., p. 109.) 

60. ^Codification of Davy's Method.— Dr. Handfield Jones has 
found that the results obtained by this plan were not so trustworthy 
as could be wished, and suggests the following modification. {^'Ar- 
chives of Medicine,' vol. i., p. 144.) 

Lately I have used a bottle, of about six ounces capacity, 



22 Davy's method of 

with a curved tube of supply, and another to conduct away the gas 
into a graduated jar (Fig. 34, Plate VI.). a is the supply tube; 
by the out-leading tube; c, fluid remaining in curve of supply 
tube; d^ mixture in bottle; ^, receiver to hold and measure the gas 
generated. After the urine is poured in, the supply tube is washed 
out with a little water. Of course, at any time, more solution of 
chlorinated soda (measured quantity) can be added through the 
supply-tube. I put into the bottle two drachms of urine or more, 
adjust the out-leading tube to the jar, and pour in, with a pipette, a 
known bulk of solution of chloride of soda.* This drives over, of 
course, a corresponding amount of air, and the gas generated, a fur- 
ther amount, so that in the jar I have an amount which —the volume 
of decomposing fluid = the gas generated. I have ascertained, by 
trial that no alteration of volume takes place when air and nitrogen 
are mixed. The fluid remaining in the curved supply-tube bars all 
escape of gas, and it is perfectly easy to empty the bottle afterwards 
by simply inverting it, when the contents pour out of the gas escape- 
tube. By shaking the bottle frequently, I can get an experiment 
finished in about an hour." 

" In six trials (some of them being made with a straight tube of 
supply, going to the bottom of the jar, instead of a curved one), I 
obtained the following results : — 

Observed. Calcnlated. 

(a) 2 grains of urea gave 3-305 C. m. instead of 3*098 C. in. or -207 + 



(6) 2 


>» 


n 


3-0979 


M 


w 


3-098 


or -0001 - 


(c) 1-6 


W 


n 


2-3107 


n 


« 


2-323 


or -0123- 


(d) 1-3 


9» 


9» 


2-1313 


n 


j> 


2-0137 


or-1276 + 


W 2-S 


» 


» 


3-8498 


ti 


99 


3-8725 


or -0227 - 


(/)2 


»> 


9> 


3-0256 


n 


» 


3-098 


or -0724- 



" These are not exact enough to satisfy me, but I do not see. any 
source of fallacy in the mode; and, if in more skilful hands it should 
prove trustworthy, I think it would have much to recommend it, on 
the score of facility in previous preparation. The figures have been 
corrected for temperature and pressure." 

* "The aolutioii of chloride of soda used by Dr. Davy is the soL sod. chlor. of the 
Dnblin * PharmacopcBia.* I find that it is not every specimen that serves the pnrpoiie 
well ; what I have nsed lately has been made for me by Mr. Button, Holborn Bars. 
A fresh solution (filtered) of chloride of lime acts very energetically and qnickly, 
mnch more so than the sol. sod. chlor., but some carbonic acid is generated and passes 
over, which complicates the process.** 



ESTIMATING UREA. 23 

51. Besnlts of Liebier's and Davy's Methods compared. — 
In some comparative experiments on Liebig's and Davy's methods, 
Dr. Handfield Jones obtained the following results : — 

Urine specific gravity 1,024, full coloured — 

By Liebig, gave 15*920 grains of urea per S i. 
By Davy, „ 16640 

Urine specific gravity 1,007, pale, clear — 
By Liebig, S i gave 5*250 grains. 
By Davy, Si „ 2*636 .„ 

Urine specific gravity 1,029, paleish, lateritious — 
By Liebig, g i gave 16*125 grains. 
By Davy, Si „ 17*224 „ 

Urine specific gravity 1,018, albumen, separated — 
By Liebig, S i gave 10*500 grains. 
By Davy, gi „ 9*760 „ 

Dr. Von Bose has also estimated the proportion of urea in the same 
specimen of urine, by the two methods. Ten cubic centimeters of six 
diflferent specimens of urine gave the following results : — 

Liebig's Method. Davy's original Method. 

1 ^ -365 gr. -310 gr. 

2 *335 „ -260 „ 

3 - -370 „ -295 „ 

4 *225 „ -269 „ 

5 -247 „ *231 „ 

6 -220 „ -253 „ 

,% The apparatus required for the volumetric analysis of urine may 
obtained of Messrs. Griffin, Bunhill Row, E.C.; Messrs. Bullock and Reynolds, 
3, Hanover Street, W. ; and at most operative chemists and philosophical 
insCniment makers. The graduated tubes may also be obtained of Messrs. 
Negretti and Co., Holbom Hill. 



24 



CHAPTER III. 



Examination and Preservation of Urinart Deposits. Col- 
lecting Urine for Microscopical Examination — Period when 
the Urine should he examined — Removal of the Deposit from 
the Vessel containing it — of Collecting a very small quantity 
of a Deposit from a Fluid- — Magnifying Powers required in 
the Examination of Urine — of the Chemical Examination of 
Urinary Deposits — Examination of the Deposit in the Micros^ 
cope — of placing the Deposit in the Preservative Fluid — 
Refractive Power of the Medium in which Deposits are 
mounted — Media in which Urinary Deposits may be pre- /j 
served — of keeping the Deposit for subsequent Inquiries-— of 
preserving Deposits permanently — MucuSy Epithelium, Fungi, 
and Vegetable Growths — Spermatozoa — Casts — Pus — Phos' 
phates, Urates, Blood Corpuscles, Uric Acid, Cystine, Oxalate 
of Lime — on preserving Crystalline Substances which are 
more or less soluble in Water. Of Extraneous Matters 
OF Accidental Presence — Larvce of the Bhw-fly — Hair — 
Cotton and Flax Fibres — Portions of Feathers — Silk — Fibres 
of Deal from the Floor — Starch Granules — Portions of Tea 
Leaves — Milk — Sputum — Epithelium from the Mouth — 
Vomit. 

Examination op Urinary Deposits. 

The examination of nrinary deposits is now a subject of such 
great importance, and the advantages derived from it are so generally 
admitted, that I need scarcely refer to its value, in assisting us to 
form a diagnosis in many cases of disease. Within the last fifteen or 
twenty years, the investigation of urinary deposits has been much 
simplified, and the results obtained by the conjoint use of the micros- 
cope and chemical analysis have been so accurate and decided, that 
the nature of the greater number of deposits has been definitely 
determined. 



MICROSCOPICAL EXAMINATION. 25 

When the student commences to examine urinary deposits for the 
first time, he will douhtless meet with many difficulties ; and in some 
specimens which he examines, he will perhaps discover no deposit 
whatever; whilst in examining others, the whole field of the micros- 
cope is seen to be occupied by substances of various shapes and 
colours, the nature of which he will be unable to ascertain. Many 
of the substances which lead to this difficulty have obtained entrance 
into the urine accidentally; and the observer should therefore be 
warned against mistakes easily made, which are serious, and may 
bring great discredit upon his powers of observation. Portions of 
hair have been mistaken for casts of the renal tubes ; starch-granules 
for cells; vegetable hairs for nerve fibres; casts for the basement 
membrane of the uriniferous tubes ; and many other substances of 
extraneous origin, such as small portions of woody fibre, pieces of 
feathers, wool, cotton, etc., often take the form of some of the 
urinary deposits, and to a certain extent resemble the drawings 
given of them in their general appearance, so as to mislead the 
student in his inferences, and retard his progress in investigation. 

52. Gollectinff TTriiie for lCiorc»copical Examination. — Urine, 
which is to be submitted to examination, should be collected in 
considerable quantity, in order to obtain sufficient of the deposit 
for examination. In many instances, the amount of sediment, 
even firom a pint of urine, is so small that, without great care in 
collecting, it may be altogether passed over. The amount of deposit 
firom a measured quantity of urine should always be roughly noted. 
The space occupied by the deposit may be compared with the total 
bulk of the fluid, and we may say the deposit occupies a fifth, a 
fourth, half the bulk of the urine, etc. 

Bottles used for carrying specimens of urine should be made of 
white glass, with tolerably wide mouths, and capable of holding at 
least four ounces ; but if the sediment only of the urine is required, 
the clear supernatant fluid may be poured ofi^, after the urine has 
been allowed to stand for several hours, and the remaining deposit 
may then be poured into small bottles of an ounce capacity, or even 
less. The only objection to this latter mode of collecting urine is, 
that no estimate of the amount of sediment deposited by a given 
quantity of urine can be formed. The bottles may be arranged in a 
case capable of containing two, four, or six. They may be obtained 



26 MICROSCOPICAL EXAMINATION 

of Messrs. Weiss, in the Strand ; Mr. Highley, 70, Dean Street, W. ; 
Mr. Matthews, near King's College Hospital ; and other instrument 
makers. 

53. Period when the TTriiie should be Examined. — In all cases 
the urine should, if possible, be examined within a few hours after 
its secretion ; and, in many instances, it is important to institute a 
second examination after it has been allowed to stand for twenty- 
four hours or longer. Some specimens of urine pass into decom- 
position within a very short time after they have escaped from the 
bladder ; or the urine may even be drawn from the bladder actually 
decomposed. Under these circumstances, we should expect to find 
the secretion highly alkaline, having a strongly ammoniacal odour, 
and containing crystals of triple phosphate, with granules of earthy 
phosphate ; and upon carefully focussing, numerous vibriones may 
generally be observed. In other instances, the urine does not appear 
to undergo decomposition for a considerable period, and may be 
found clear, and without any deposit, even for weeks after it has 
been passed. 

In those cases in which uric acid or octohedral crystals of 
oxalate of lime are present, the deposit increases in quantity after 
the urine has stood for some time. These salts are frequently not 
to be discovered in urine immediately after it is passed, but make 
their appearance in the course of a few hours. The deposition of 
uric acid depends upon a kind of acid fermentation, which has been 
the subject of some beautiful investigations by Scherer (§ 119). 

In order to obtain sufficient of the deposit from a specimen 
of urine for microscopical examination, we must place a certain 
quantity of the fluid in a conical glass (§ 12) ; in which it must be 
permitted to remain for a sufficient time to allow the deposit to 
subside into the lower part. 

54. Removal of the Deposit from the Vessel containing it. — 
In order to remove the deposit from the lower part of the vessel in 
which it has subsided, the upper end of the pipette is to be firmly 
closed with the forefinger, the tube being held by the thumb and 
middle finger. Next, the lower extremity is to be plunged down to 
the bottom of the deposit. The forefinger may now be raised very 
slightly, but not completely removed, and a few drops of the fluid 
with the deposit slowly pass up into the tube (Fig. 9, Plate IL). 



OF URINART DEPOSITS. 27 

When a suflficient quantity for examination has entered, the fore- 
jfinger is again pressed firmly upon the upper opening, and the 
pipette carefully removed. A certain quantity of the deposit is 
now allowed to flow from the pipette on to the glass slide or cell, 
hy gently raising the forefinger from the top. It is then covered 
with the thin glass cover, and subjected to examination in the 
usual way. Dr. Venables recommends that the deposit should be 
obtained by inverting a corked tube into which the urine has been 
previously poured. A small quantity of the deposit adheres to the 
cork, and may be removed to a glass slide ; but, as a general rule, 
the plan above described will be found efficient. 

66. Of GoUectinff a very small quantity of a Deposit ttom. a 
Fluid. — When the quantity of deposit is very small, the following 
plan will be found of practical utility. After allowing the lower 
part of the fluid which has been standing, to flow into the pipette, 
as above described, and removing it in the usual manner, the finger 
is applied to the opening, in order to prevent the escape of fluid 
when the upper orifice is opened by the removal of the finger. 
The upper opening is then carefully closed with a piece of cork. 
Upon now removing the finger from the lower orifice, the fluid will 
not run out. A glass slide is placed under the pipette, which is 
allowed to rest upon it for a short time. It may be suspended with 
a piece of string, or supported by the little retort stand. Any 
traces of deposit will subside to the lower part of the fluid, and 
must of necessity be collected in a small drop upon the glass slide, 
which may be removed and examined in the usual way. 

Another plan is to place the fluid, with the deposit removed by 
the pipette, in a narrow tube, closed at one end, the bore of which 
is rather less than a quarter of an inch in diameter. This may be 
inverted on a glass slide, and kept in this position with a broad 
elastic India-rubber band. The deposit, with a drop or two of 
fluid, will fall upon the slide, but the escape of a further quantity 
of fluid is prevented by the nature of the arrangement, which will 
be understood by reference to Plate VI., Fig. 33. 

66. ULeLSsnifying Powers required in the Examination of the 
Urine. — Urinary deposits require to be examined with different 
magnifying powers. The objectives most frequently used are the 
inch and the quarter of an inch. The former magnifies about 40 

c 3 



28 MICROSCOPICAL EXAMINATION 

diameters ( x 40) ; the latter from 200 to 220 ( x 200, x 220). Large 
crystals of uric acid may be readily distinguished by the former, 
but crystals of this substance are sometimes so minute that it is 
absolutely necessary to use high powers. Octohedra of oxalate of 
lime are frequently so small that they cannot be seen with any 
power lower than a quarter ; and, in order to bring out the form 
of the crystals, even higher object-glasses than this are sometimes 
necessary. Spermatozoa may be seen with a quarter, but they then 
appear very minute. In these cases, an eighth of an inch object-glass, 
which magnifies about 400 diameters ( x 400), will be of advantage. 
The casts of the tubes, epithelium, and the great majority of urinary 
deposits, can, however, be very satisfactorily demonstrated with a 
quarter of an inch object-glass. 

A deposit, the nature of which is doubtful, should be subjected 
to examination in fluids possessing different refractive powers, such 
as water, serum, mucilage, glycerine, turpentine, Canada balsam, etc. 

67. Of the Chemical Examination of Urinary Deposits. — tn 

the investigation of those deposits which are prone to assume very 
various and widely different forms, such as uric acid, it will often be 
necessary to apply some simple chemical tests, before the nature of 
the substance under examination can be positively ascertained. 

Suppose for instance, a deposit which is found, upon microscopical 
examination, not to possess any characteristic form, be suspected to 
consist of uric acid, or of an alkaline urate, it is only necessary to 
add a drop of solution of potash, which would dissolve it, and then 
excess of acetic acid, to obtain the crystals of uric acid in their well- 
known rhomboidal form. Other chemical tests which should be 
considered necessary may be applied afterwards. 

When it is requisite to resort to chemical reagents, a drop of the 
test-solution is to be added to the deposit, which is placed in the 
cell, or upon the glass slide. The little bottles described in § 34 will 
be found most convenient for this purpose. If necessary, heat may 
be applied to the slip of glass by a spirit-lamp, and, with a little 
practice, the student will soon be able to perform a qualitative 
analysis of a few drops of urine, or of a very small portion of a 
deposit. 

68. Examination of the Deposit in. the Hicroscope. The 

drop of urine with the deposit is to be placed in a thin glass cell, or 



OP URINARY DEPOSITS. 29 

in one of the animalcule cages (§ 30, Plate V., Figs. 24, 26). 
These instruments will be found convenient for examining urinary 
deposits, as a stratum of fluid of any degree of thickness can be 
very readily obtained. A simple form of compressorium may be also 
conveniently used for the examination of urinary deposits (Plate VI., 
Fig. 35). 

Various parts of the specimen are to be brought into the field 
of the microscope. It is better to examine the object as regularly 
as possible, commencing on one side, and moving it up and down, 
until the whole has been traversed. After one specimen has been 
examined, and the nature of its contents noted, another may be 
treated in a similar manner. Specimens should be taken from the 
deposit at different levels, for while some deposits soon sink to 
the bottom, others are buoyed up, as it were, either by the small 
quantity of mucus which the urine contains, as is the case with 
small crystals of oxalate of lime, or by the flocculent nature of the 
deposit itself. 

As each part of the deposit is brought under the field of the 
microscope, the observer should endeavour to recognise every object 
as it passes under his view. This, however, will for some time be 
found a matter of considerable difficulty, arising partly from the 
number of deposits which commonly occur together, and partly 
from the very various forms which many of these substances are 
liable to assume, but chiefly, I believe, from the great number 
of substances of accidental presence which are found in almost 
every specimen of urine subjected to examination ; especially in 
urine obtained from the wards of a hospital, upon which the first 
microscopical observations are usually made. Accurate copies 
of the different urinary deposits, drawn on the stone with the aid 
of the glass reflector (§ 33), are represented in the plates of the 
" lUtistrations of Urines Urinary Deposits ^ and Calculi." 

I cannot too strongly recommend the observer to sketch the 
appearances of the different deposits which come under his notice. 
He will by so doing become familiar with the characters of urinary 
deposits much more quickly than if he merely instituted a hasty and 
imperfect examination. The methods of obtaining sketches of the 
exact size of the image in the microscope, are described in ** How to 
Work with the Microscope,'^ (See also § 33.) 



30 PRESERVATION OF 

On the Preservation of Urinary Deposits as Permanent 
Microscopic Objects. 

A desire has been generally expressed that a series of the most 
important urinary deposits should be kept for sale, so that practi- 
tioners might have an opportunity of readily obtaining named 
specimens, with which the deposits that from time to time fall 
under notice might be compared, and their nature recognised. 
Persons who prepare and sell microscopic objects have experienced 
great difficulty in preserving urinary deposits satisfactorily ; and 
many specimens which have been purchased have been found to 
lose their characters after a few months, and have soon become 
quite useless objects. Feeling strongly the real practical value of 
preparations of this kind, it seems to me very desirable that a few 
rules with regard to the preservation of urinary deposits should be 
laid down ; and I therefore propose to allude briefly to the diflferent 
plans which I have found to succeed best. I hope that, shortly, 
there will be no difficulty in obtaining series of well-mounted and 
illustrative specimens.* At the same time, any one attending 
hospital practice, who has a little time at his disposal, can, without 
much trouble, prepare such preparations for himself. 

The different characters of urinary deposits render necessary 
different plans of preservation. It is, therefore, desirable to con- 
sider the nature of the deposit before we attempt to preserve it. 
Some deposits may be preserved dry, others may be mounted in 
Canada balsam. A certain number exhibit their characters very 
well if preserved in glycerine, while many can only be kept in 
certain aqueous fluids. 

69. — Of placing the Deposit in the Preservative Fluid. — 
After the deposit has been allowed to settle in a conical glass, the 
supernatant fluid is to be poured off; and if it is to l)e mounted in 
fluid, a quantity of the preservative solution, equal in bulk to the 
urine and deposit that remain, is to be added. After the deposit 
has again settled, the fluid is to be poured off and replaced with an 
equal portion of fresh preservative solution. In this way the 
deposit is washed clean, and properly impregnated with the pre- 
servative fluid. 

* Specimens of urinary deposits may be obtained of Messrs. Smith and Beck, Cole- 
man Street, City; Mr. Tennant, 149, Strand; and Mr. Matthews, sargical instnunent 
maker, Carey Street, Lincoln's Inn Fields. 



URINARY DEPOSITS. 31 

When preparations are to be preserved in a fluid medium, a 
small shallow water-tight cell is to be used. The specimen and its 
preservative fluid being placed in the cell, the thin glass is applied, 
and the cover cemented in its place with the aid of Brunswick black 
or other cement. ("How to Work with the Microscope^) In 
washing urinary deposits prior to mounting them, it is often neces- 
sary to add some compound to the water used for this purpose, in 
which they are known to be insoluble ; and sometimes it is desirable 
to add some substance to increase the density of the fluid; for which 
purpose, certain salts, syrup, or glycerine may be employed, accord- 
ing to circumstances. Many deposits, although soluble to some 
extent in pure water, are quite insoluble in a weak acid; others 
are insoluble in a weak alkali or in certain saline solutions. Again, 
it is sometimes desirable to separate certain substances in the 
deposit from others, and this may be effected by special chemical 
solutions which have the power of acting on the one and not upon 
the other; or, in cases where one is more dense than the other, 
by agitating the deposit with water, and, after allowing time for 
the heavier deposit to settle, pouring off" the lighter one into another 
vessel, to subside there. From this, it may be collected in the 
usual way. 

60.— TTrinaxy Deposits preserved as Dry Objects. — If the 
preparation is to be preserved as a dry object, water is to be added 
in the first place ; and a portion of the deposit, which has thus been 
carefully washed, is to be removed with the aid of a pipette to the 
glass slide, and the fluid allowed to evaporate, the whole being 
covered by a bell-jar, and placed over a dish of strong sulphuric 
acid. When dry, it is to be protected from dust by a thin glass 
cover. The glass cover is easily prevented from pressing upon the 
preparation by interposing a thin piece of paper or cardboard ; or a 
thin India-rubber ring, which may be easily fixed to the glass slide 
and thin glass cover, by a little gum made into a thick paste with 
whiting, may be used. 

61. — Preservation in Canada Balsam. — If the specimen is to 
be mounted in Canada balsam or turpentine, it is to be dried in the 
manner just described, warmed slightly, wetted with turpentine or 
balsam, and mounted with the usual precautions. {^^How to Work 
with the Microscope.^*) 



32 PRESERVATION OF 

62.— Befractive Power of the Hedium in which Deposits 
are KCoimted. — The appearance of objects in the microscope de- 
pends very much upon the medium in which they are immersed ; 
and many structures are so altered in their character by different 
media, that they would hardly be recognised as the same object. It 
may be said, generally, that the darker the object, and the more 
dense its structure, the higher should be the refireictive power of the 
medium in which it is mounted — thus the dark-coloured uric acid, 
or the thick spherical crystals of carbonate of lime, and the dumb- 
bells of oxalate of lime, exhibit their structure to the greatest 
advantage when mounted in the highly refracting Canada halsam, 
or in strong syrup or glycerine, while the beautifully transparent 
octohedra of oxalate of lime would be scarcely visible in these 
media, and require to be mounted in an aqueous fluid which pos- 
sesses a lower degree of refractive power. Many of these objects, 
when mounted dry, appear quite dark, and scarcely exhibit any 
structure at aJl, in consequence of the great difference in the 
refracting power of their substance, and the air by which they are 
surrounded. From what has been said, it will be evident how im- 
portant it is to examine the same object in different media— in 
fact, it is quite impossible to form an idea of the real structure of 
many specimens, without proceeding in this manner. {"How to 
Work with the Microscope" p. 59; and " The Microscope in its Appli- 
cation to Practical Medicine" second edition, §§ 74, 89, and 90.) 

63. — Media in which Urinary Deposits may be Preserved. — 

Urinary deposits may be mounted in air, in turpentine, oil, or 
Canada balsam; in glycerine, in gelatine and glycerine, in solution 
of naphtha and creosote, in certain saline solutions, in weak spirit, 
and in some other aqueous solutions, which will be alluded to. The 
glycerine which I use is " Price^s patent glycerine,^^ diluted with 
one third part, or more, of water. In making more dilute solutions 
of glycerine, it is well to employ camphor water, as this prevents 
the formation of fungi. Many urinary deposits may be preserved 
in strong glycerine, if care be taken to increase the density of the 
solution gradually, and sufficient time be allowed for the deposit to 
be thoroughly permeated with the fluid. The best plan is to add 
a little glycerine to the deposit which has been allowed to collect 
in the conical glass. After the deposit has settled, pour off the 



URINART DEPOSITS. 83 

supernatant fluid and add fresh glycerine. Repeat the same process 
two or three times. I have kept specimens preserved in strong 
glycerine for ten years with very slight change ; and probably they 
will retain their character for a much longer time than this. 

The composition of the naphtha and creasote fluid, above re- 
ferred to, is as follows: — 

Solution of Naphtha and Creasote. 

Creasote 3 drachms. 

Wood naphtha 6 ounces. 

Distilled water 64 ounces. 

Chalk, as much as may be necessary. 

Mix first the naphtha and creasote, then add as much prepared 
chalk as may be sufficient to form a smooth thick paste ; afterwards 
add, very gradually, a small quantity of the water, which must be 
well mixed with the other ingredients in a mortar. Add two or 
three small lumps of camphor, and allow the mixture to stand in a 
lightly covered vessel for a fortnight or three weeks, with occasional 
stirring. The almost clear supernatant fluid may then be poured 
off" and filtered, if necessary. It should be kept in well corked or 
stoppered bottles. 

64. Of keeping: the Urinary Deposit for subseatient Inqui- 
ries.— In cases where it is desirable to retain a certain quantity of 
the deposit in the preservative solution for subsequent examination, 
or for the purpose of making more preparations, it should be kept in 
a small glass tube, with a tight-fitting cork, and carefully labelled. 
Most urinary deposits may be kept for a longer time in this manner 
than if mounted in thin cells. I propose now to describe briefly the 
various plans adapted for the preservation of urinary deposits which 
I have found to succeed best. 

Pbesbrvation op Special Deposits. 

65. KCucns. — It is very difficult to preserve the character of the 
so-called " mucus corpuscles," or imperfectly formed epithelial cells, 
nuclei, and granules, which constitute the slight flocculent deposit 
met with in healthy urine, and termed "mucus." The naphtha and 
creasote solution is best adapted for the purpose, and it is desirable to 
place the specimen in a cell about the twentieth of an inch in depth. 

c 6 



34 PRESERVATION OF 

66. Epithelium.— The different varieties of epithelium are easily 
preserved, althongh, after the lapse of some time, minute oil globules 
make their appearance in them. They may be kept in naphtha and 
creasote fluid, to which one-fourth of its bulk of glycerine has been 
added. It is well to put up specimens of epithelium from the 
urethra, bladder, ureter, and pelvis of the kidney, removed from the 
organs of a healthy man who has been killed accidentally. They 
should be mounted in very thin cells. Specimens of the epithelium 
from the vagina, which can generally be obtained from the urine of 
females, should also be preserved. 

67. Vegretable Growths: Fungi.— I have found thatfiingi may 
be preserved most satisfactorily in glycerine, for although they appear 
somewhat more transparent in this fluid than in urine, they preserve 
their general character better than when immersed in other preser- 
vative fluids. It is necessary to add weak glycerine in the first 
instance, and to increase the strength gradually, otherwise the fungi 
become collapsed, owing to the great density of the strong solution. 
A solution composed of equal parts of water and Price's glycerine is 
sufficiently strong to preserve fungL I have not been able to preserve 
specimens of sarcinse which I have met with on two or three occasions 
in the urine, probably in consequence of their extreme delicacy. The 
sarcinse which are from time to time met with in vomit keep per- 
fectly well, and preserve their recent characters in glycerine. 

68. Spermatozoa are sometimes mounted in the dry way; but 
although their general form is preserved, their refractive power and 
transparent appearance are so different from what is observed when 
they are immersed in urine, that little is gained from such prepara- 
tions. Spermatozoa keep very well in glycerine, although they 
appear rather more faint than in an aqueous fluid. They should be 
examined with the eighth of an inch object-glass ( x about 400); but 
when the eye of the observer has become familiar with the general 
appearances, they may be readily recognised with a quarter of an 
inch object-glass ( x about 200). 

60. Casts.— It is not difficult to preserve the character of some 
varieties of casts. The transparent casts often become covered with 
numerous minute granules and oil globules, and their character much 
altered. Granular casts and epithelial casts often keep very well in 



URINARY DEPOSITS. 85 

the naphtha and creasote solution; but altogether I prefer glycerine, 
with one-third part of water. Although, in many instances, the cells 
they contain are altered, and oil globules appear much more trans- 
parent than when in urine, this alteration in character may be easily 
allowed for. The specimens in glycerine, of course, keep admirably. 
I have some specimens of large waxy casts and epithelial casts which 
have been kept in the naphtha and creasote solution for upwards of 
seven years, and still preserve their characters welL Some casts may 
also be preserved in gelatine and glycerine, care being taken that the 
mixture is not made too hot. Casts may be coloured slightly with 
an ammoniacal solution of carmine, and preserved in glycerine. The 
very transparent casts, which are hardly visible under ordinary cir- 
cumstances, can thus be demonstrated very clearly and preserved. 
Any nuclei in the cast are intensely coloured by the carmine. 

70. Pus. — Recent specimens of pus may be so readily obtained 
that it is hardly necessary to attempt to preserve the corpuscles 
permanently. Their characters alter so much in all the aqueous 
preservative fluids that I have tried, that after they have been 
put up for some time, it would be difficult to recognise the nature 
of the preparation. I have, however, succeeded in preserving some 
specimens of pus in glycerine by observing the precautions mentioned 
in § 63. Cancer cells, which are sometimes found in very large 
qnantities in the urine in cases of cancer of the bladder, may be 
preserved in the same manner. I have several specimens which 
have been mounted for five or six years. 

71. Phosphates. — The phosphate of lime, in its amorphous form, 
in globules, and minute dumb-bells, is easily preserved in weak 
spirit, naphtha and creasote fluid, or glycerine ; but the character of 
the crystals of the triple or ammoniaco-magnesian phosphate could 
not be retained in this solution. As is well known, this salt is quite 
insoluble in solutions of ammoniacal salts, and these make the best 
preservative solutions for it. Crystals of triple phosphate may be 
kept for any length of time, with their smooth surfaces and their 
lustre unimpaired, in distilled water, to which a little chloride of 
ammonium has been added. Phosphate of lime and the stellar form 
of triple phosphate may be dried carefully, and mounted in Canada 
balsam ; but, of course, the appearance of the crystals is a good deal 
altered. 



36 PRESERVATION OF 

72. Urates.— As the urates are so commonly met with, and as they 
are generally deposited in the form of granules, there is scarcely any 
need of mounting them as permanent objects. If desired, however, 
deposits of this kind may be preserved by adding a little naphtha 
and creasote fluid to the deposit, which should be left in it for a 
considerable time before it is put up. Urates which crystallize in 
small spherical masses, as often occur in the urine of children, and 
more rarely in irregular branched processes, may be preserved very 
well in Canada balsam, or, if preferred, they may be kept in the 
naphtha and creasote fluid. 

78. Blood Corpuscles become more or less altered in most 
preservative fluids. I think that those which I have mounted in 
glycerine (one part water to three parts of glycerine) have under- 
gone the least change. 

74. Uric Add CryetaJa are easily preserved as permanent 
objects. The usual plan is to mount them in Canada balsam. They 
should be washed, in the first instance, with a little water, to which 
a few drops of acetic add have been added. When pretty clean, 
they may be placed upon a glass slide, with the aid of a pipette, 
and the greater quantity of the fluid absorbed with a small piece 
of bibulous paper. After the crystals have been properly arranged 
on the slide with a needle, they may be dried, by exposure under a 
bell jar over a dish containing sulphuric acid. When quite dry, 
they may be moistened with a drop of turpentine, and mounted in 
Canada balsam. In this operation, a very slight heat should be 
employed, otherwise the crystals will become cracked in all direc- 
tions, and more or less opaque. Uric acid crystals, as a general rule, 
do not keep well in glycerine. In cases where we wish to preserve 
other substances in the deposit as well as uric acid crystals, the 
naphtha and creasote fluid will be found to answer very well. I 
have some preparations mounted in this manner, which were put up 
six or seven years ago. 

76. Cystine.— Crystals of cystine may be preserved in Canada 
balsam, the same care being taken in mounting them as mentioned 
under uric acid, or they may be kept very well in distilled water, or 
in the naphtha and creasote fluid, to which a little acetic acid has 
been added. 



URIXARY DEPOSITS. 37 

76. Oxalate of Lime.—Both the octohedra and dumb-bells may 
be preserved for many years in the naphtha and creasote solution and 
also in glycerine. • The octohedra look very transparent in the latter 
fluid. The dumb-bells may also be mounted in Canada balsam, in 
which medium the octohedra are almost invisible. When required 
for polarising, these and other crystals should be put up in balsam. 

77. On Preservin^r Crystalline Compounds obtained from 
Urine.— It is exceedingly difficult to preserve many of the crystalline 
substances obtained from urine in a moist state; but several of them 
form beautiful microscopic objects when carefully dried. Urea, 
nitrate of urea, oxalate of urea, creatine, creatinine, alloxan^ hippuric 
acid J murexid, and many others, may be kept as permanent objects 
in this manner. In order to prepare them, it is better to cause 
them to crystallize upon a glass slide ; allow the mother liquor to 
drain off, and immediately place the slide under a bell-jar over 
sulphuric acid. Sometimes the crystals may be made in a small 
evaporating basin, and when drained and dried, a portion of them 
may be removed to a glass cell, and covered with a piece of thin 
glass to exclude the dust. Many crystals may be examined and 
preserved for a considerable time in their own mother liquor, espe- 
cially when they are very slightly soluble in fluid ; but, as a general 
rule, this plan does not answer very satisfactorily, for, independently 
of the escape of the fluid from the edges of the cell, a few of the 
largest crystals grow still larger at the expense of the smaller ones, 
and the beauty of the specimen is destroyed. The different forms of 
these crystals, as they appear in the microscope, are given in the 
^ lUtistrations of Urine, Urinary Deposits j and Calculi,''^ ^^Urine,"^^ 
Plates I. to IX.; see also "T^ Microscope in its Application to 
Practical Medicine,'** chap, ix., p. 292. 

Of Extraneous Matters. 

78. Importance of recosTiisinff Extraneous Matters. — In the 
microscopical examination of urinary deposits, the observer often 
meets with substances the nature and origin of which he cannot 
readily determine. This is due, in many instances, to the presence 
of bodies which have fallen in accidentally, or which have been 
placed in the urine for the express purpose of deceiving the prac- 
titioner. The importance of recognising matters of an extraneous 



38 EXTRANEOUS MATTERS 

origin can scarcely be sufficiently dwelt upon, for until the eye 
becomes familiar with the characters of these substances, it will 
obviously be quite impossible to derive such information from a 
microscopical examination of the urine as will enable the observer 
to distinguish between those bodies, whose presence denotes the 
existence of certain morbid conditions, and certain matters which 
have accidentally found access, which, clinically speaking, may be 
entirely disregarded. Practitioners who use the microscope for 
investigating the nature of urinary deposits, will derive advantage 
from subjecting many of the substances referred to separately to 
microscopical examination, so that when met with in the urine, their 
nature may be at once recognised. As most of the undermentioned 
substances are readily obtained and easily subjected to examination, 
a brief notice of their character will be sufficient. Attention should 
be especially directed to the fact of the frequent occurrence of many 
of these extraneous substances in urine, and the observer should 
particularly notice those characters in which they resemble any 
insoluble substance derived from the bladder or kidney, or deposited 
from the urine. 

The following are some of the most important of these extraneous 
matters which have fallen under my own notice : — 

Hunan hair. Milk. 

Cat's hair. Oily matter. 

Blanket hair. Potato starch. 

Worsted. Wheat starch. 

Wool. Bice starch. 

Cotton and flax fibres. Tea leaves. 

Splinters of wood. Bread crumbs. 

Portions of feathers. Chalk. 

Fibres of silk. Sand. 

The microscopical appearances of some of these substances are given 
in Plate VIII., Figs. 36, 37, and 38, see also Plates I., II., and III., 
Figs. 1 to 16, of the " Illustrations of Urine, Urinary Deposits and 
CalcuW^ It would hardly be believed what curious and unexpected 
substances are sometimes found in the urinary secretion. Some 
time since, a specimen of urine was sent for examination, which 
contained several white bodies, about half-an-inch in length, like 
maggots. Upon microscopical examination, I found that these con- 



EXTRANEOUS MATl^ERS IN URINE 



PlJ^TE VII. 



Fig. 3n. 




^^^^ 



9 ^^' /f\ 



X Jlo. 



§ 85. X 215. 



^1^. 3S. 




IN URINE. 39 

tained trachesB, and they ultimately proved to be larva of the blowfly j 
although it had been stoutly affirmed that they had been passed by 
the patient from his bladder. 

70. Sesatdoxide of Iron. — ^A few years ago, Dr. Stewart in- 
formed me that a man had brought some urine to him for examination, 
with a thick, brick-red deposit, which was analysed by Mr. Taylor, 
and proved to consist of sesquioxide of iron. The urine containing 
this deposit, was of specific gravity 1*011; and upon the addition of 
ammonia, a brown flocculent precipitate (hydrated sesquioxide of 
iron) was thrown down. Dr. Stewart tells me, that a considerable 
quantity of the powder (jeweller's rouge, or sesquioxide of iron) 
remained suspended in the urine after it had stood for many hours, 
and that the fluid was still turbid after having been passed through 
a double filter. The man who brought this urine has been endea- 
vouring for some time to impose upon difierent hospital physicians. 

80. Hair of various kinds is very frequently found amongst 
unnstry deposits, but, as its microscopical appearance is so well known, 
it is not necessary to enter into a description of the characters by 
which it may be distinguished. The varieties of hair most commonly 
found are human hair, blanket hair, and cat's hair. Not unfrequently 
portions of coloured worsted will be met with ; but the colour alone 
will often remove any doubts with reference to the nature of the 
substance. Portions of human hair are sometimes liable to be 
mistaken for transparent casts of the uriniferous tubes, which are 
quite destitute of epithelium or granular matter, and which present 
throughout a homogeneous appearance. The central canal, with the 
medullary cells within it, in many cases, will be sufficient to dis- 
tinguish the hair from every other substance likely to be mistaken 
for it (Plate VII., Fig. 38a) ; but sometimes this cannot be clearly 
made out, and the marks on the surface may be indistinct; when 
attention must be directed to its refracting power, well defined 
smooth outline, and also to the sharply truncated or fibrous ends, or 
to its dilated club-shaped extremity in the case of the hair-bulb. In 
the latter points, small portions of hair will be found to differ from 
the cast, for this latter does not refract so strongly; the lines on each 
side are delicate, but well defined, and the ends are seldom broken so 
abruptly as in the case of the hair. Caf s hair (Fig. 38&) can scarcely 
be mistaken for any urinary deposit with which I am acquainted. 



40 EXTRANEOUS MATTERS 

and its transverse markings will serve at once to distinguish it with 
certainty. {^^Illustratiom,'' Plate I^ Figa 1, 2, 3.) 

81. Cotton and Flax Fibres are very often found in urine (Fig. 
38 d^ e). When hroken off" in very short pieces, they may be mis- 
taken for casts; but the flattened bands of the former {e\ and the 
somewhat striated fibres of the latter (d\ will generally be found 
sufficiently characteristic. {^^lUmtrations,'' Plate III., Fig. 16; Plate 
I., Fig. 4) 

82. Portions of Feathers are often detected in urinary deposits 
upon microscopical examination, and are derived, no doubt, from the 
bed or pillow (Fig. 38^). The branched character of the fragments 
will always enable the observer to recognise them with certainty. 
(''Illustrations^" Plate III., Fig. 14.) 

83. Pieces of Silk are not unfrequently present, but these can 
scarcely be mistaken for any substance derived from the kidney. 
Their smooth glistening appearance and small diameter, at once 
distinguish them from small portions of urinary casts, and their clear 
outline and regular size from shreds of mucus, <fec. 

84. Fibres of Deal from the Floor. — Of all the extraneous 
matters likely to be met with in urine most calculated to deceive the 
eye of the observer, none are more puzzling than the short pieces of 
single fibres of deal (Plate VII., Fig. 36). In hospitals, where the 
floor is uncovered, and frequently swept, portions of the fibres of the 
wood are detached, and being light, very readily find their way into 
any vessel which may be near. In fact, these fibres enter largely 
into the composition of the dust which is swept up. I was familiar 
with the appearance of these bodies for a long time before I ascer- 
tained their nature ; for, although the peculiar character of coniferous 
wood is sufficiently well marked, when only very small portions are 
present, and in a situation in which they would scarcely be expected 
to be met with, their nature may not be so easily made out. Often 
only two or three pores may be seen, and not unfrequently these are 
less regular than usual, in which case they may be easily mistaken 
for a small portion of a cast with two or three cells of epithelium 
contained within it. I have very frequently met with these fibres 
amongst the deposit of various specimens of urine which have been 



IN URINE. 41 

obtained from private as well as from hospital patients. (" TUustra- 
tions," Plate III., Fig. 15.) 

85. Stardi Qranules are very commonly found in urinary 
deposits, and indeed in all matters subjected to microscopical exa- 
mination ; usually their presence is accidental, but large quantities 
of starch have often been added for purposes of deception. Their 
true nature may be discovered, either by their becoming converted 
into a jelly-like mass on being, boiled with a little water in a test- 
tube, by their behaviour upon the addition of free iodine, or by their 
well-defined microscopical characters. Certain cases have been 
recorded, in which it was maintained that the starch granules 
present in the urine had passed from the kidney; but it need 
saarselj Be said that such an origin is very improbable, if not quite 
impossible. In cases where due care has been taken to prevent the 
access of starch globules after the urine had been passed, none were 
observed. We learn by experience that we can seldom receive the 
statements of patients upon these matters, however positive they 
may be. They often deceive themselves as to the actual occurrence, 
in their own case, of what never has occurred and never can occur. 
The three kinds of starch most likely to be met with in urine are 
potato starch (Plate VII., Fig. 37), wheat starch (Fig. 38^), and 
rice starch. They are readily distinguished by microscopical exa- 
mination. Small portions of potato, or pieces of the cellular 
network in which the starch globules are contained, have been occa- 
sionally met with. Under the head of starch may also be included 
bread-crumbs (Fig. 38^), which are very commonly present in urine, 
and have a very peculiar appearance, which may be so easily observed, 
that a description would appear superfluous. Many of the starch- 
globules will be found cracked in places, but their general characters 
are not otherwise much altered. {"Illustrations,^^ Plate II., Figs. 6, 7, 
8, 9, 10, 11.) 

86. Portions of Tea-leaves are occasionally found in urine (Fig. 
38/). The beautiful structure of the cellular portions, and the ^ 
presence of minute spiral vessels, distinguish this from every other 
deposit of extraneous origin. A small piece of a macerated tea-leaf 
will be found to form a most beautiful microscopic object. {"Illus- 
trations," Plate I., Fig. 5.) 



42 EXTRANEOUS MATTERS 

87. Dlilk and certain Ooloiirlngr 2Catters are sometimes pur- 
posely added to urine ; and it is often difficult to make out whether 
they have been added with the intention of deceiving us, especially 
as urine is sometimes met with, having all the appearance of milk 
(chylous urine) ; and certain colouring matters, such as logwood and 
indigo, when taken into the stomach may be absorbed by the vessels, 
and eliminated from the system in the urine. A form of Indigo, 
there can be no doubt, is actually produced in the urine. 

Urine, to which milk has been added, can be distinguished from 
the so-called chylous or milky urine by its microscopical characters. 
The presence of small oil-globules, with a well defined dark outline, 
can always be detected, in milk by the aid of the microscope, while in 
chylous urine nothing but a great number of very minute and scarcely 
visible granules, composed of fatty matter, can be made out (" lUm- 
trations," Plate III., Fig. 13.) I have had several specimens of milky 
urine sent to me for examination, upon the supposition that they 
were examples of chylous urine, and in some the milk had been 
added in sufficient quantity to yield a firm curd, after standing for a 
day or two, and a precipitate upon the addition of acetic axjid. Where 
only a very small quantity of milk is added, the difficulty of deciding 
positively is greatly increased. The globules are, I believe, charac- 
teristic. Some cases of chylous urine are recorded, in which the fatty 
matter existed in distinct globules; and therefore we cannot unfor- 
tunately lay it down, that in all cases of this dise^ipe, the fatty matter 
is in a molecular state. In the six or seven true cases of chylous 
urine, which have been brought under my own notice, the fatty 
matter was in this very minute state of division; and in several 
supposed ones, in which oil-globules were present, they were proved 
to have resulted from the addition of milk for the purpose of deception, 
or from the use of an oiled catheter. The observer should also be 
fjamiliar with the appearance of oil-globules under the microscope 
(Fig. 12). 

88. Sputum : Epithelium from the Mouth : Vomit. It must 
be remembered, too, that epithelium from the mouth is often found 
in urine. All the cells met with in sputum are occasionally found, 
and a vast number of different substances, which are rejected by 
vomiting, are from time to time detected. The observer must not be 
surprised at finding now and then some well defined elementary fibres 



IN URINE. 43 

of striped muscle. It is most diflScult to prevent these different 
substances from being mixed with the urine. They often cause the 
microscopist great trouble — and especially at first, before the eye has 
become quite familiar with their appearance, they are likely to give 
rise to the greatest confusion in descriptions of microscopical ap- 
pearances. For the microscopical characters of the substances present 
in sputum and vomit, I must refer to " The Microscope in its appli- 
cation to Practical Medicine,^* and the Plates in the third part of 
^ lUustrations of the use of the Microscope in Clinical Medicine'^ 



44 



CHAPTEE IT. 



The Anatomy of the Kidney — Its Action in Health and 
Disease — Cortical and Medullary Portions of the Kidney 
— Pelvis — MamillcB — In/undibula and Calyces — Artery — 
Vein — Nerves — Lymphatics — Secreting Apparatus — The 
Uriniferous Tube — Of the Circulation in the Kidney — 
Epithelium — Of the Baseme^it Membrane of the Tubes and 
of the so-called Matrix — On some Points connected with the 
Physiology of the Kidney — On the formation of Coasts of the 
Uriniferous Tubes — Of the Cast — Circumstances under 
which the Renal Secretion may be altered in Quantity or 
Qiuility — On the Absorption of Substances from the Stomachy 
and their excretion in the Urine — Morbid Changes affecting 
the Structure of the Kidney — Of BrighVs Disease — Dr, 
JohnsorCs Investigations, 

It is clearly impossible to discuss with advantage the cha- 
racters of the urine in health and disease, or the formation of 
urinary calculi, without studying the anatomy and action of the 
kidney. As these organs are essentially concerned in the removal 
from the organism of soluble substances resulting from disinte- 
gration, the accumulation of which in the blood would most seriously 
impair the action of many important organs, they are worthy of 
special study on the pari; of every physician. It is not too much to 
say that, without a good knowledge of the anatomy and physiology 
of the kidney, it is impossible for the practitioner to understand the 
nature of a very large and important class of diseases, and it is 
certain that cases of one or other form of renal disease will very 
frequently come under the notice of all engaged in practice in 
large cities. Nor are kidney diseases exclusively confined to the 
inhabitants of cities. Moreover, there are no diseases in which the 



ANATOMY OF THE EIDNET. 45 

practitioner can be of more real service to the patient, and none 
which it is more important to recognise at once. The treatment of 
many of these morbid conditions has been satisfactorily determined, 
and there is no department of medicine in which the knowledge we 
possess is more definite and accurate, or in which the practical 
utility of our knowledge is more manifest. A thorough acquaint- 
ance with the physiological changes occurring in the kidney will 
alone enable us, to the greatest advantage of our patients, to 
suggest and apply remedies in various cases of disease. For these 
reasons, therefore, I consider it right to describe briefly the anatomy 
and action of the kidney before considering the characters of the 
urine. 

I shall describe the anatomy as simply as I can, and in order to 
spare words I have made several drawings to illustrate the structure 
and arrangement of the various tissues entering into the formation 
of the renal apparatus. The subject is so extensive that I cannot 
hope to do more than ofier some very brief remarks; and I shall 
omit discussing many points connected with the pathology which 
would be necessary to give my account any pretensions to com- 
pleteness. 

89. General Anatomy.— The general anatomy of the kidney is 
shown in section in the diagram (Fig. 39, Plate VIII.). Each kidney 
is enclosed in a capsule composed of fibrous tissue, but abundantly 
supplied with blood-vessels, and with lymphatics. At the hilus or 
notch, the capsule is continuous with the areolar tissue which 
surrounds the large vessels, and extends in intimate relation with 
them for a certain distance into the interior of the organ. Fig. 39, 
Plate VIII. show9 the general structure of the kidney as seen upon 
section. The ureter traced upwards is continuous with the pelvis of 
the kidney. From the pelvis^ narrow funnel-shaped prolongations 
(infundihvla) are observed. These extend to the pyramids, being 
reflected around the apex of each to form a cup-shaped depression 
(calyx). The apices of some pyramids are also seen opening into 
the infundibula towards the observer. The cortex extending round 
the kidney and passing inwards between the pyramids, is easily 
distinguished from the medullary portion, by the irregular granular 
appearance it presents to the unaided eye, and by the numerous 
minute points (Malpighian bodies) seen in it. The medullary 



46 CORTEX — ^BIEDULLA — ^PELVIS. 

portion is composed of the pyramids, which consist of tubes which 
are nearly straight, and converge to the apex or mamiUa, where 
they open by about fifteen or twenty orifices. Portions of arteries 
and veins are observed between the infundibula, and smaller vessels 
are seen in the section between the cortex and medulla. These give 
branches in two directions, outwards to the cortex, and inwards to 
the pyramids. The drawing is about two-thirds of the natural size. 
The scale at the side is divided into eight spaces, representing 
half-inches. 

00. Cortex. — The cortex or cortical portion of the kidney con- 
sists of a layer about half an inch in thickness, forming the surface 
of the entire organ, and dipping down often to the depth of an inch 
between the pyramids. 

91. Medullary Portion.— This lies immediately within the cortex, 
and is directly continuous with its inner surface. It is composed of 
from ten to fifteen pyramids, their bases being continuous with the 
cortex; their apices free, and projecting into the cavity in the 
interior of the organ (pelvis of the kidneyj, 

92. Pelvis: UamilleB: Inftuxdibula : Calyces. — The mucous 
membrane, with the fibrous and muscular tissue externally, forms a 
dilated cavity in the interior, called the pelvis (c, Fig. 40). From 
the pelvis, passing towards the apices of the pyramids, are several 
tubular prolongations, fgrming funnel-shaped channels (infundibula), 
e, d, usually not more than twelve in number. In many cases, two 
pyramids open into one infundibulum. Each of these funnel-shaped 
prolongations forms a cup-like cavity round the tip of the pyramid 
{mamilla or papilla), called a calyx, f. Lastly, the mucous mem- 
brane, after forming this reduplication, is firmly adherent to the 
mamillse, and immediately continuous with that lining the tubes, 
which open by orifices varying from ten to twenty or more in 
number, upon the summit (h, Fig. 40, Plate VIII.). Some of the 
free extremities of the pyramids are thin, and extend in a longi- 
tudinal direction, perhaps for the distance of a quarter of an inch 
or more. The term mamilla or papilla can hardly be properly 
applied to these. 

The pelvis is dilated at the notch or hilus, where it leaves the 
kidney, and soon contracts to a tube with muscular parietes (ureter), 



ARTERY — ^VEIN — NERVES. 47 

which Opens into the bladder — one on each side of this viscus, at its 
posterior aspect. Fig. 40, Plate VIII., represents a thin section of a 
portion of the kidney, a, cortical ; b, medullary portion ; c, pelvis ; 
d, infundibulum; e, opening of an infundibulum into pelvis; /, calyx; 
g, pyramid; h, mamilla or papilla; i, adipose tissue; k, large veins 
divided in making the section. Small arteries are also seen cut 
across in different parts of the section, some large branches being 
situated between the cortex and medullary portion of the organ. 

93. Artery.— Outside the mucous membrane of the pelvis of the 
kidney, the artery, entering at the hilus behind the vein, divides 
into branches, which are distributed to the organ. The branches of 
the artery do not anastomose, but radiate outwards as they divide 
and pass towards the cortex. Arrived at a point between the cor- 
tical and medullary portions of the kidney, many branches pursue 
for some distance a more or less horizontal, or rather curved course, 
corresponding to the bases of the pyramids. From these, radiating 
outwards in the cortex, pass a number of nearly straight branches, 
which give off" on all sides little vessels which terminate in Mal- 
pighian bodies. The great bulk of the blood carried by the artery 
to the kidney is distributed to Malpighian bodies ; but a few small 
arterial branches pass straight through the cortex, and supply the 
capsule; others are distributed upon the external surface of the 
pelvis, and ramify amongst the adipose tissue in the neighbourhood ; 
while some {vasa recta) are given off" from the vessels that lie 
between the cortex and medulla, many branches of which I have 
shown, anastomose with each other, and pass in the substance of the 
pyramids towards their apices. 

04. The Emnlgreiit or Benal Vein is formed by the union of a 
number of smaller trunks which receive the blood from the capil- 
laries. Numerous large branches may be seen in the intervals 
between the cortex and medulla (Fig. 40, Jc), They converge from 
all points, receiving the blood distributed by the artery as above 
described, and at length form one large trunk, which emerges at the 
hilus at its anterior part, and opens into the inferior cava. 

85. Nerves. — The nerves are branches of the sympathetic, and 
are distributed upon the coats of the artery. They may be traced 
for a considerable distance into the interior of the gland, always 



48 URINIFEROUS TUBES. 

accompanying the subdivisions of the artery. I have seen brandbef 
on the Malpighian arteries, but have not been able to ascertain how 
they terminate. It is possible that small branches may pass into 
the Malpighian tuft. I have seen numerous very fine braodiei of 
nerve fibres passing between the uriniferous tubes of the frog's Iddnqr. 
The kidney of the frog receives many branches of nerve fibres, beindef 
those which pass into it with the artery. In the human subject lU 
the arteries and the vasa recta are freely supplied with nerve-filra 
and numerous very fine fibres, with nuclei connected with them 
(^^ connective tissue corpuscles" of authors), lie around the tabes. 

06. LyxnplLatios.— There are numerous lymphatic vessels dis- 
tributed to the kidney. They leave the organ at the hilos^ when 
the large vessels enter. I have not succeeded in injecting these lym- 
phatics as I have in the case of the liver, where they exist in gml 
number, and are found both in the substance of the capsule and in 
the portal canals. The capsule of the kidney is, probably, also 
supplied with lymphatics, although it is not easy to demonstrate 
them by injection. 

97. Secretingr Apparatus: TTriniferoiis Tubes. — ^The secreting 
apparatus consists of tubes lined with epithelium. The tube com- 
mences in a small flask-like dilatation, which embraces the capillary 
vessels of the Malpighian tuft (Fig. 41, Plate VIII.). In continuar 
tion with this is the tube which, in the greater part of its extent, is 
very much convoluted, being frequently bent upon itself; so that a 
great length of secreting tube is packed in a very small space. The 
convoluted tubes are so close together, that it is impossible to trace, 
in man and mammalian animals generally, the course of one indi- 
vidual tube for any great distance; and, in thin sections of the cortex, 
segments of the windings of different tubes are seen divided in all 
directions. 

The tubes, as they are about to leave the cortex, pursue an almost 
straight course, and here commences the ductal portion of the urinary 
apparatus. A certain number of these straight tubes extend nearly 
to the surface of the kidney, and carry off the secretion firom the tubes 
which lie most superficially. These may be seen lying in the cortex, 
at certain intervals. In the pyramids, the tubes are straight ; and 
as they converge, they unite together, and become fewer in number; 
while their calibre greatly increases as they pass towards the apex 




It or. 



To nice i>oig«' ^5^. 



CIRCULATION IN THE KIDNEY. 49 

of the pyramid, where they open as hefore descrihed. Some of these 
orifices are figured in Plate XXII., Fig. 5, Vol. i., ^^ Archives of 
Medicine, 1859." 

98. Suzninaxy of Stmotnre. — The cortex of the kidney, then, is 
composed of Malpighian bodies, the flask-like dilatations and convo- 
luted portion of the uriniferous tubes, with capillaries, the arrange- 
ment of which will he presently considered, branches of arteries and 
Teins, with a certain amount of transparent and fibrous tissue. 

The medullary portion is composed of the pyramids, which are 
formed of the straight portion of the uriniferous tubes with capil- 
laries, bundles of small straight branches (vasa recta) from the arte- 
ries, and numerous straight branches of small veins; the majority 
of these nearly straight vessels, however, consists of vessels resulting 
firom the division of the efferent vessels of the Malpighian bodies 
situated nearest the pyramids (Plate IX., Fig. 42). There is also an 
intervening material containing nuclei, and having a very firm con- 
sistence, but not a distinctly fibrous network or stroma. 

99. Circulation in the Kidney. — The course of the blood, as it 
circulates in the vessels of the kidney, may now be described. 
Starting from the arterial branches between the cortex and medul- 
lary portion of the organ, the blood pursues two directions — out- 
wards towards the external surface, and inwards towards the apices 
of the pyramids. 

Of the blood which passes outwards, a little is distributed to the 
capsule and membrane of the pelvis, but .by far the larger propor- 
tion is carried to the Malpighian bodies. Arrived at the Malpighian 
body, the trunk of the little artery divides into three or four dilated 
branches, each being as wide as the artery itself. These subdivide 
into capillary loops which have their convexity towards the urin- 
iferous tube, and which lie uncovered by epithelium within its dilated 
commencement ; so that fluids passing through the membranous 
walls of these capillaries, and, indeed, everything escaping from them 
when they are ruptured, must at once pass into the uriniferous tube. 
The blood is collected from the capillaries by small venous radicles 
which lie in the central part of the tuft, which there unite to form a 
single efferent vessel that emerges usually at a point very close to 
that by which the artery entered. In some specimens, I have seen 
two and even three efferent vessels, but this is not common. 

D 



50 VASA RECTA. 

The arrangement of the secreting structure and vessels of the 
kidney of man, magnified about 50 diameters, is represented in the 
drawing, Plate VIII., Fig. 41; a, Malpighian body; fe, Malpighian 
artery or afierent vessel; c, efferent vessel; d, capillary network, 
into which the blood passes from the efferent vessel; e, small venous 
radicle, which carries off the blood after it has traversed the 
capillaries just alluded to; /, commencement of the uriniferous tube 
by a dilated extremity, which embraces the vessels of the tuft; g, 
the tube; near the point where it opens, it joins others, h, to pursue a 
straight course towards the pyramids of the kidney; t, another tuft, 
the vessels of which are empty and shrunken; ^, portion of a tube 
cut across, showing the basement-membrane. The attention of the 
reader is particularly directed to this figure. 

The efferent vessel of the tuft pursues a short course, and then 
divides into an extensive network of capillaries, in the meshes of 
which the tubes ramify. It is from the blood, which, after passing 
through one system of capillaries in the tuft, thereby losing much of 
its witer, slowly wanders in a more concentrated state, through this 
extensive capillary system, that the solid constituents of the urine 
are separated by the agency of the epithelial cells lining the tubes. 
The water,/M/Zy charged with oxygen, transuding from the capillaries 
of the Malpighian body, is made to traverse in succession the epi- 
thelial cells lining the tube. At the same time that it dissolves the 
different substances which have been separated from the blood, it 
oxidises the matter forming the outer part of the cells, and converts 
it into soluble substances. The blood becomes richer and richer in 
solid constituents as it approaches the straight portion of the tube. 
From the intertubular network of capillaries above alluded to, the 
blood is collected by small venous radicles, which at last pour their 
contents into the renal or emulgent vein. 

100. Va4Ba recta.— Of the comparatively small quantity of the 
blood which passes inwards towards the apex of the pyramids, a very 
small portion passes into vessels which supply the walls of the pelvis 
and adipose tissue. The remainder is conducted towards the apex of 
the pyramid by the vasa recta, or branches resulting from the 
division of small trunks of the artery, one of which is represented at 
a, Plate IX., Fig. 42. These vasa recta terminate in a capillary 
network, in the longitudinal meshes of which the straight portion 



EPITHELIUM. 51 

of the tubes lies. It must not be concluded, however, that all the 
straight vessels in the pyramids are vasa recta, with the structure of 
arteries; for the efierent vessels of those tufts near the pyramids 
divide into long and nearly straight branches, which pour their blood 
into this system of capillaries, from which it is collected by radicles 
which also pursue a straight course, and unite together to form small 
trunks, which open into branches of the vein lying between the 
cortical and medullary portions of the kidney. This arrangement 
was fully described by Bowman in his memoir. He thought that all 
the straight vessels came from the Malpighian bodies. Virchow 
seems to consider that all, or very nearly all, the straight vessels 
consist of vasa recta; but I have shown by transparent injections 
that many of these vessels are the efierent vessels from Malpighian 
bodies, as Bowman long ago stated, while a certain number undoub- 
tedly come directly from arteries (Plate IX., Fig. 42). The latter 
have the structure of arteries, and are freely supplied with nerve 
fibres. In diseases, in which much more blood is made to pass into 
the pyramids than normally, the coats of these arterial branches 
become much thickened, and the circular fibres are more readily 
demonstrated than in health. (" On the Vasa Recta in the Pyramids 
of the Kidney," Archives ofMedicinCy No. IV., 1859.) 

It should be mentioned, that the intertubular capillaries are 
everywhere continuous; and from this network venous radicles arise 
at certain intervals. The arrangement of the capillaries is well 
shown in the frontispiece of the ^^Illustrations of Urine, Urinary 
Deposits, and CalculV^ 

101. Epitheliimi.--The epithelium of the kidney difiers in difie- 
rent parts of the tube. That in the convoluted portion of the tube is 
described as being polygonal ; it projects into the tube to the extent 
of one-third of its calibre. That in the straight portion of the 
tube is flatter, and approaches to the scaly variety of epithelium. 
Although the convoluted portion of the tube is much wider than the 
straight portion, the diameter of the channel is much wider in the 
latter position than in the formery owing to the much greater thick- 
ness of the epithelium in the secreting portion of the tube. Epi- 
thelium from the convoluted portion of the uriniferous tube is 
represented in Plate IX., Fig. 44; a, treated with acetic acid, x 215. 

In healthy human kidneys, I have never seen the outline of the 

j> 3 



52 MATRIX 

cells so distinctly as figured in various works, or in the upper part 
of my own figure. The round body, usually termed the nucleus, is 
very clear and well defined, and this seems to be surrounded by a 
quantity of soft granular matter. I think it very doubtful if there 
is a cell wall external to this. In many cases of disease, the round 
central body is all that can be made out ; and sometimes these are 
found in great number in the urine. The round 'cells' present in 
the urine, in cases of acute nephritis, are generally the nuclei of the 
* cells' lining the uriniferous tube, the soft granular material around 
having been completely disintegrated. By the action of acetic acid, 
nucleoli may be observed. It would seem as if the granular matter 
external to the rounded granular body (nucleus) was altered in cha- 
racter under certain circumstances. From numerous observations, 
I feel compelled to dissent from the descriptions generally given both 
of the kidney and liver epithelium, inasmuch as the appearance of 
a cell-wall can only be seen under certain circumstances; and in 
many animals there is undoubtedly no such structure. I would 
rather say that the so-called nuclei are embedded in a granular 
material, by which they are separated from each other by nearly 
equal distances, as represented in the lower part of Fig. 44, Plate 
IX. If, instead of using the terms nucleus, cell-wall, and cell con- 
tents, we consider the central mass as germinal or living matter, 
which is coloured by carmine, and the outer granular matter as 
" formed material," the changes actually observed can be described 
without any diflSculty or confusion. The formed material is rendered 
transparent by acetic acid, as represented at a. Fig. 42, and during 
life it is slowly converted into soluble substances by the action of the 
oxygen dissolved in the water discharged from the Malpighian 
capillaries. 

The epithelium in the straight portion of the tube is much flatter 
than that in the convoluted part, and probably serves the office of a 
protective covering. It is doubtful if it takes part in secretion. 
The epithelium from the pelvis of the kidney is represented in Plate 
IX., Fig. 45, and that from the ureter in Fig. 46. 

102. Matrix and Basement-Membrane of the Tubes. — The 
basement-membrane is easily demonstrated by washing a thin section 
of the kidney, so as to remove the epithelium. It is much stronger 
and thicker in the pyramids than in the cortex (Plate IX., Fig. 436). 



Fig. 42. 



ANATOMY OF THE KIDNEY. 




tOO^HS i I , 



§ § 98, 100 



Fig. 44. 



^^ 



Fig. 45. 



r^' 



§ 101 



Fig. 43. 



Plate IX. 




§ 101 X 215 



B^. 46. 



% y^ ^ ' 



§ 101 



X 216 




Fig. 47. 



Fig. 4S. 




§ 102. X 100 




^ To /cice page Vi 



OF THE KIDNEY. 53 

The so-called matrix described and delineated by Goodsir, 
Kolliker, Dr. G. Johnson, and others, I have not succeeded in 
demonstrating to my satisfaction ; for, when the capillaries of the 
kidney have been distended with transparent injection, I have failed 
to demonstrate any fibrous structure at all resembling the drawings 
given of it, between the wall of the tube and that of the vessels. The 
appearance considered to be fibrous matrix is easily seen in any thin 
section of an uninjected kidney which has been washed and examined 
in water; but in such a section it is imposible to distinguish the 
walls of the tubes, those of the capillaries, and the so-called fibrous 
matrix, from each other. It has been figured by many as a distinct 
structure ; and Plate IX., Fig. 47, representing a section which has 
been washed in water, gives the appearance most distinctly. The 
capillaries are not injected, and, being collapsed and shrunken, 
exhibit the fibrous appearance which is considered to depend upon 
the matrix. Fig. 48 represents an injected specimen from the same 
kidney, which does not exhibit any indication of fibrous tissue 
existing between the vessels and the tubes. The nuclei in the coats 
of the vessels, and some nuclei external to them which are probably 
connected with nerve fibres, are distinctly seen, but no fibrous matrix 
is observable. Here and elsewhere, as I have shown, the stretched 
and crumpled capillaries produce an appearance resembling fibrous 
tissue or matrix of the kidney {^^ Archives of Medicine^' No. III., 1858). 
A thin section of the cortical portion of a kidney, which had been 
slightly washed in water, is also represented in Plate IX., Fig. 43. 
The vessels are not injected, a, convoluted portion of uriniferous 
tube; h, a portion of a tube stripped of its epithelium; c, outline of 
tube and crumpled capillaries, having a fibrous appearance — the so- 
called matrix; d, very small Malpighian body. Loops of vessels 
shrunken, showing cells in their walls, x 215. 

This so-called matrix has been compared to the ultimate ramifi- 
cations of Glisson's capsule ; and it has been considered necessary as 
a support to the structures of which the gland is composed. I have 
never seen fibrous tissue in the situation described in health in either 
gland ; and it is quite obvious that the structures do not require any 
supporting tissue, as they mutually support each other; and any 
matrix would tend to increase the distance between the secreting 
cells and the blood; while we certainly find in these organs every 
arrangement to reduce this as far as possible consistently with 



54 PHYSIOLOGY. 

strength. If this matrix exists, it ought to be developed as a struc- 
ture distinct from the tubes and vessels; but it has not been demons- 
trated at an early stage of development of the kidney or liver by 
anyone. In a careful examination of embryonic structures generally, 
one cannot fail to be struck with the absence of such fibrous or con- 
nective tissue, which is by some regarded as an essential part of every 
organ. It is at this early period that the tissues are softest, and 
seem most in need of support ; and yet the embryonic structures are 
peculiarly destitute of any supporting fibrous framework whatever. 
The morbid changes are explained as well by supposing the formation 
of a new material between the walls of the tubes and those of the 
vessels, or by a thickening or other change in one or both of these 
structures, as by attributing them to an alteration in the matrix or 
intertubular areolar or fibrous tissue {Bindegewebe), 

The conclusions to which I have arrived, frx)m numerous inves- 
tigations on this subject, may be summed up as follows : — 

1. In the cortical portion of the kidney there is no evidence of 
the existence of a ^^Jibro-ceUular matrix.'^ 

2. The fibrous appearance observed in thin sections of the kidney 
which have been immersed in water is due to a crumpled, creased, 
and collapsed state of the membranous walls of the secreting tubes 
and capillary vessels. 

3. A small quantity of a transparent and faintly granular material, 
with distinct nuclei, the nature of which has not yet been conclu- 
sively determined, is alone to be demonstrated between the walls of 
the tubes and the capillary vessels. 

4. The changes met with in disease can be folly explained without 
supposing the existence of 2k fibrous matrix, 

103. On some Points connected with the Physiology of the 
Kidney.— The course of the blood has been fully described, and it 
has been shown how eminently adapted the Malpighian tuft is to 
facilitate the free escape of the watery parts of the blood. The 
influence of the nervous system upon the secretion of urine is well 
known. Nerves may be traced upon the large arteries, and followed 
on the small vessels for a considerable distance. I have seen nerves 
upon the Malpighian arteries which may be traced up to the tuft. 
I have not succeeded in demonstrating nerves in connexion with the 
capillaries of the tuft; but a careful examination of several specimens 



COLLATERAL CIRCULATION. 55 

has led me to conclude that these capillaries are supplied with nerves, 
as is also the case with the capillaries of the ciliary processes of the 
eye, and some other capillary vessels. In many cases, the so-called 
"connective-tissue corpuscles" external to capillary vessels, belong 
to exceedingly fine nerve fibres, which are only to be demonstrated 
with the utmost difficulty. I am now investigating the mode of 
distribution of the nerves to vascular structures, and I hope soon to 
be able to express myself more positively on these very interesting 
questions. 

The appearance of some of the capillary vessels of the Malpighian 
tuft of the human kidney, separated and, to some extent, flattened 
out, is represented in Plate X., Fig. 49. The vessels were injected 
with dilute Prussian blue injection. The nuclei connected with their 
walls are well seen : a, a few coils separated from the rest of the tuft; 
ft, part of a loop somewhat compressed, showing the nuclei a little 
flattened ; e, tissue connecting the coils with each other, in conse- 
quence of which the globular form of the tuft is preserved, even 
when it is removed ; d, a small portion of a capillary compressed as 
much as possible, showing the thickness of the capillary wall at 
the point of reduplication. 

Collateral Circulation, — Virchow lays considerable stress on the 
existence of a collateral circulation through the vasa recta. He 
considers that the circulation in the medullary portion of the kidney 
is more free than it is in the cortex, because the blood in the latter 
region does not pass through Malpighian bodies. There can be no 
doubt of the correctness of VirchoVs views upon this question, and 
I can confirm many of his statements from personal observation. 
Some years ago, in examining some specimens of diseased kidney, I 
was much struck with the thickness of the walls of some of the vasa 
recta in the pyramids. Upon further examination, these were found 
to exhibit the circular muscular fibres so characteristic of arterial 
walls. I have since carried out further investigations upon the 
healthy kidney, and have proved that many of the straight vessels 
running parallel with the tubes in the pyramids of the kidney are in 
reality small arterial branches with muscular walls. I suspect that 
some of these branches communicate very readily with the veins in 
the same situation; and it is not impossible that, in health, the 
blood may be caused to pass through the Malpighian bodies, or may 
be diverted, and, by passing through the vasa recta, be returned to 



56 ACTION OF 

the veins more rapidly. This subject is one of very great interest, 
in connexion with the renal circulation. 

In a state of health, the diminished rapidity of the circulation in 
the capillaries of the Malpighian body, consequent upon the greatly 
increased area of the capillaries, which the blood must traverse as it 
flows from the small artery, which alone supplies them, favours the 
transudation of water through the capillary walls. This fluid must 
at once pass into the uriniferous tube; and as it gradually traverses 
in succession the cells which line it, the soluble substances are 
dissolved out — ^the quantity of solid constituents gradually increasing 
as the solution passes down the tube, while the substances are being 
more fully oxidized at the same time. Now the blood just brought 
from the Malpighian body has parted with water, and, being more 
concentrated, is richer in urinary constituents than the blood in any 
other part of the kidney. This is conducted by the vessels into 
which the efferent vessel of the Malpighian body divides, to the 
upper part of a uriniferous tube below the Malpighian body. We 
should expect that the cells in this region would be more fully 
charged with soluble urinary constituents than those lower down 
the tube; and, in accordance with this view, we find that these cells 
are acted upon by the almost pure water which has just escaped from 
the capillaries of the Malpighian bodies; while, by the time the fluid 
has reached the cells at a lower point of the tube, it is already 
charged to a great extent with soluble constituents, and its solvent 
power is, of course, proportionately diminished. 

Not the least important office of the cells lining the convoluted 
portion of the uriniferous tube is undoubtedly that of separating from 
the blood a considerable quantity of the (Ubris of blood-corpuscles, in 
the form of extractive matters. It is almost certain that the cells 
have the power of altering some of the substances they separate from 
the blood, and converting them into these peculiar urine extractives, 
the physiological importance of which must be very great, as so 
large an amount is excreted. 

Some observers have considered that special vessels are concerned 
in carrying blood to nourish the tissues of the gland, and Dr. Good- 
fellow thinks that the intertubular capillaries are concerned in this 
office. The quantity of blood passing into these vessels is, however, 
far greater than is required for the nutrition of the tissues of the 
kidney, and reasons have been already advanced for accepting the 



MALPIGHIAN BODY. 57 

view propounded by Bowman with reference to these capillary vessels. 
The tissues of organs generally, are nourished by the plasma present, 
and do not require special vessels. Many arguments may be adduced 
against the view, that the hepatic artery merely serves the purpose 
of distributing blood to nourish the tissues of the liver, as is 
generally supposed. 

The views of Bowman, with regard to the office of the Malpighian 
body and the epithelium of the uriniferous tube, have been opposed 
by Ludwig, and more recently by Dr. Isaacs, in America, who tried 
to prove that the solid constituents were separated by an epithelium, 
covering the capillaries of the Malpighian body (which, if it exists, is 
certainly very unlike glandular epithelium generally, and the cells 
must be very much smaller than he has represented); while, strange 
to say, he does not attempt to show what office is performed by that 
enormous extent of epithelial surface in the convoluted portion of 
the 'tube, or why the very peculiar relation between the extensive 
system of capillaries around the tubes and that of the Malpighian 
body exists. Dr. Goodfellow thinks that the urinary constituents are 
separated with water from the Malpighian capillaries, and that any 
constituents of the serum, or blood, that may have transuded through 
their walls, " are absorbed by the epithetical cells of the tubules or 
by some other agents."* There does not seem to be any positive 
evidence that any constituents of the serum do really transude 
through the Malpighian capillaries. The epithelium is not of the 
character of that we find usually concerned in absorption; and other 
objections might be urged against this view, especially certain facts 
observed in connection with the uriniferous or corresponding organs 
of some of the lower animals. It seems to me, that Bowman's views 
on the physiology of the kidney are supported by so many different 
arguments, that they will be accepted by all who have carefully 
studied the subject, from the different points of view which he has 
indicated. Many absolutely new facts must be discovered before the 
conclusions which he arrived at can be rejected. 

104. On the Formatiozi of Casts of the TTriniferoTis Tubes. — 
Such, then, being the actions of the kidney in health, we may now 
consider briefly how these changes may be modified in certain cases. 
If the arterial walls were relaxed, more blood would pass into the 

♦ ''* Lectures on Diseases qftlte Kidney^" p. 152. 

D 5 



58 THE FORMATION 

Malpighian capillaries in a given time, and a great transudation of 
water would take place. If, on the other hand, the arteries became 
contracted, the secretion of urine would be diminished accordingly. 
Many sudden and temporary alterations in the circulation of the 
blood through the Malpighian bodies of the kidney undoubtedly 
depend upon an influence exerted through the nerves alone; but 
certain changes which are, unfortunately, of a more permanent 
character, are due to an altered action of the secreting cells. The 
rapidity of the circulation in the Malpighian body will be greatly 
influenced by the rate at which the blood traverses the capillaries 
around the uriniferous tubes; the flow of blood in these vessels being 
governed by the attractive force exerted by the cells within the 
tubes for the urinary constituents dissolved in the concentrated 
blood. Now if, from any cause, the action of the secreting cells 
became impaired, and they ceased for a time to exert their attraction 
for the constituents they ought to separate from the venous blood, a 
retardation to the circulation in these capillaries would result. This 
would afiect backwards, as it were, the capillaries of the Malpighian 
tuft, in which the blood, urged on through the arteries, would tend 
to accumulate. Their thin walls, being much stretched, would not 
resist the passage of certain constituents of the blood; albumen and 
extractive matters would pass into the tube, and escape in the urine. 
Supposing this state of things to go on, the pressure on the Mal- 
pighian capillaries must necessarily increase; and these capillaries, 
distended to their utmost, and their walls stretched to the last 
degree, would at length burst, and all the constituents of the blood, 
including the blood-corpuscles, would pass into the tube, and would 
escape with the urine. The tenuity of the walls of the Malpighian 
capillaries, which permits the escape of water in health, will favour 
the escape of other constituents of the blood, and increase the 
chance of their rupture in disease, if they be exposed to increased 
pressure; but the collateral circulation already referred to in some 
measure counteracts such a tendency. 

Professor Virchow has lately arrived at the conclusion that 
albumen and other constituents of the blood more frequently 
escape from the straight vessels of the pyramids than from those of 
the Malpighian bodies. According to this view, the constituents 
of the blood would have to pass through the walls of the tubes, 
as well as through those of the capillaries, in which case we 



OF CASTS. 59 

ought to find an (edematous condition of the kidney, and blood 
effused between the tubes more frequently than is the case. It seems 
to me that, before such a lesion was possible, the Malpighian capil- 
laries must have become much thickened and altered in structure. 
In many chronic cases, as has been shown by Dr. Johnson, the Mal- 
pighian arteries become enormously thickened; and I have often 
observed the capillaries of the Malpighian body in a like condition; 
so that the permeability of their walls must be very greatly di- 
minished. There can be no question that in many cases the blood- 
corpuscles and fluid matters escape from the Malpighian capillaries, 
for they may be seen in the convoluted portion of the tubes after 
death, and I have seen bodies extravasated from the vessels even in 
the capsule of the Malpighian body. 

105. Casts. — In many cases of congestion, and in inflammation 
of the kidney, a spontaneously coagulable material is effused into 
the tubes, and coagulates there, forming a cast or mould of the tube, 
which is gradually washed out by the fluid which is secreted behind 
it, and thus it finds its way into the urine, from which it may be 
easily separated for examination. 

A cast is composed of a coagulable material which is effused into 
the uriniferous tube; and, becoming solid there, it entangles in its 
meshes any structures which may be in that part of the tube at the 
time, and forms a mould of the uriniferous tube. The characters 
vary very much in different cases, according to the state of the 
tubes and the part in which the effusion of the matter takes place. 
Various substances are often entangled in the cast; and, by ob- 
serving the character of these, we are often enabled to ascertain 
the nature of morbid changes going on in tubes at the time the cast 
was being formed. Great difference of opinion has been expressed 
with reference to the nature of the material of which the cast is 
composed. By some it has been termed fibrine; but the striated 
appearance always present in coagula of this substance is not found 
in the cast. Others have considered the cast was composed of 
albumen ; but it is not rendered opaque by means of those reagents 
which produce precipitates in albuminous solutions. Not more than 
five years since, it was stated by two observers in France and 
Germany of high reputation, at least in other branches of scientific 
inquiry, that the cast really consisted of the basement membrane of 



60 CASTS OF THE TUBES. 

the uriniferous tube. How such a statement could be made by any 
one possessing even a slight knowledge of the anatomy of tissues, it 
is difficult to conceive. 

The transparent material probably consists of a peculiar modi- 
fication of an albuminous matter possessing somewhat the same 
characters as the walls of some epithelial cells, the elastic laminsB 
of the cornea, the walls of hydatid cysts, etc., but not condensed like 
these structures. I think it not improbable that these casts of the 
uriniferous tubes may really be composed of the material which, in 
health, forms the substance of epithelial cells. In disease, this sub- 
stance, perhaps somewhat altered, or not perfectly formed, collects 
in the uriniferous tubes, and coagulates there. This receives some 
support from the fact that occasionally casts are formed although 
no albumen passes into the urine. According io this notion, it is 
possible that a cast might be formed quite independently of any 
congestion or morbid condition of the Malpighian tuffc; but, as a 
general rule, there can be no doubt that serum escapes and albumen 
is found in the urine. 

The diameter and general character of the cast will be determined 
by the state of the uriniferous tube at the time of its formation, as 
the researches of Dr. Johnson have indisputably proved. If the 
epithelium be abnormally adherent, the cast will be very narrow ; 
if, on the other hand, the epithelium be removed, it will be of the 
width of the tube. Should the epithelium be disintegrating, the 
cast will afford evidence of the change. If in a state of fatty de- 
generation, fat-cells will be entangled in it. In haemorrhage from 
any part of the secreting structure, blood-corpuscles are present ; 
and, when suppuration occurs, the cast contains pus-corpuscles. 
When the transudation of the coagulable material occurs in a tube 
to which the epithelium is intimately adherent, or in a tube whose 
walls are smooth, the cast will be clear and perfectly transparent. 
The import of all these different characters is fully discussed in the 
works of Dr. Johnson ; and several interesting cases, under obser- 
vation for a considerable period of time, will be found reported in 
Dr. Basham's work. 

The different forms of casts which are most frequently met with 
will be considered under the head of urinary deposits. 

Professor Virchow thinks that casts are very constantly, if not 
entirely, formed in the straight portion of the uriniferous tubes ; but 



MUCOUS CASTS. 61 

many of the facts already referred to strongly militate against this 
idea, and it is common enough to see the casts in the tuhes of the 
cortex. Moreover, as I have demonstrated in several cases, the cast 
receives successive layers upon its outer surface, as it passes down 
the tube {^'Illustrations," Plates XIV. and XVI.). There is no doubt 
that casts are found in the straight as well as in the convoluted 
portion of the uriniferous tubes, but the value of the characters of 
the cast found in the former situation with regard to diagnosis 
cannot be questioned, while it is obvious that from casts found in 
the straight portion of the tubes we can learn nothing as to the 
nature of morbid changes occurring in the secreting part of the 
gland. In Plate X., Fig. 50, portions of casts from the convoluted por- 
tion of the tubes are seen embedded in transparent material. The 
drawing was taken from specimens found in the urine of a case of 
acute suppurative nephritis. It is probable that the small casts were 
found in the convoluted portion of the uriniferous tubes, and that the 
transparent material in which they were embedded, coagulated in the 
straight portion of the tube, near its opening, at the summit of a 
papilla. We may, therefore, conclude that casts are generally formed 
in the convoluted portion of the tube, although, in certain cases, the 
coagulable matter may be efiiised in the straight portion also, in 
which case the diameter of the cast will be very much greater than 
if it was formed entirely in the convoluted part of the uriniferous 
tube. In certain cases in which there is evidence of considerable 
irritation in the kidneys, sometimes so much as to lead one to 
suspect the existence of calculus in the kidney, a number of floccu- 
lent shreds may be passed in the urine. I have seen several cases 
in which these were composed of a very transparent and slightly 
granular material like ordinary mucus. In Fig. 83, Plate XVIL, is 
represented such a cast which must have been entirely formed in 
the straight portion of the tubes. The ramifications from the larger 
mass extended into the fine tubes which open into the larger ones 
in considerable number. The drawing ( x 75) was taken from speci- 
mens found in the urine of a patient under the care of my friend, 
Mr. Charles Hawkins, who had been sufiering from renal irritation 
and affection of the bladder for many years. 

106. Circumstanoes under which the TTrine may be altered 
in Quantity or duality. — In the remarks I am about to make, I 



62 ALTERATION OF URINE 

sliall consider it as proved that the solid constituents of the urine are 
separated by the cellsf lining the uriniferous tubes, while the water 
filters through the walls of the capillaries of the Malpighian body. 
Diuretics may act in two ways — 1. By causing increased transudation 
of fluid from the Malpighian tuft, in which case pale urine, con- 
taining very little solid matter, will escape in considerable quantity; 
2. By causing the cells to separate from the blood, a larger amount 
of solid material, in which case a highly concentrated urine, rich in 
solid matter, will be secreted in greater proportion than in health. 
In certain diseases, there seems to be a tendency on the part of the 
kidneys to throw off morbid material which exists in the blood. If, 
under these circumstances, the flow of blood to the kidneys is not 
compensated for by rapid removal of these matters, congestion, 
perhaps running on to inflammation, occurs, and there is danger of 
serious damage to the organ. 

It is in this manner that the albuminuria following scarlatina, 
and that coming on from exposure to cold, are to be explained. 
This subject has received full consideration from Dr. Johnson, in his 
work " On Diseases of the Kidney" and also in that " On Cholera," 
The action of many irritating diuretics is to be explained in a 
similar manner. A quantity of cantharides, which would do no harm 
to a strong healthy man with sound kidneys, would produce dangerous 
congestion and inflammation, with rupture of the capillaries of the 
Malpighian body, in a person who was recovering from an illness, or 
in one whose kidneys were affected by disease. In the one case, the 
secreting power of the cells appears increased by the action of the 
drug; while in the other they are incapable of effecting the increased 
amount of work suddenly thrown upon them, and the results above 
described must occur. Kramer and Golding Bird state that squill, 
capaiba, broom, juniper, and guiacum, cause the removal of an in- 
creased proportion of water from the blood, but do not influence the 
quantity of solid matter removed from the body in twenty-four hours. 
It seems probable that these remedies affect the capillaries of the 
Malpighian tuft, either directly, or perhaps more probably, through 
their action upon the nerves distributed to the renal vessels. 

In cases where the blood is very watery, the excess of fluid is 
carried off by the kidneys; but at the same time, a greater amount 
of solid matter is removed in a given time, partly arising from the 
tissues being washed out by the large quantity of fluid, and partly 



IN QUANTITY OR QUALITY. 63 

because the formation of urea, &c., is £a,YOured by a dilute state of 
the fluids. 

Many neutral salts (nitrates, sulphates, &fi,) seem to increase the 
secretion of urine by being attracted from the blood in a state of 
solution, in all probability by the renal epithelium, the kidney being 
the channel by which they naturally leave the system. Urea has a 
similar diuretic action. Within certain limits, the greater the 
quantity of these substances in the blood, the more will be removed 
by the renal epithelium, supposing this to be healthy. The more 
strongly the epithelial cells be charged with urinary constituents, 
the greater the quantity of water required to dissolve them out. 
This seems to be effected as follows : — ^When the urinary constituents 
are not removed from the cells by the water coming down from the 
tufb as fast as they are separated from the blood, they must accumu- 
late until the surcharged cell ceases to exert that attractive force 
upon the blood in the capillaries around the tube which it does 
ordinarily. The tendency to stasis in the circulation thus caused 
necessarily interferes with the free passage of the blood through the 
Malpighian capillaries, and the increased pressure which results 
causes the escape of fluid into the tube, which washes out the solid 
matter accumulated in the cells. The latter resume their action, 
the circulation becomes free again, and the normal relation between 
»the action of the cells of the tube and the Malpighian body is 
re-established. 

Now alkalies, and especially the citrates, tartrates, and acetates, 
which become converted into carbonates in the system, increase not 
only the quantity of water removed from the system, but also mate- 
rially augment the proportion of solid matter. These salts increase 
the quantity of urea and other matters formed. They seem to favour 
the conversion of the products resulting from the disintegration of 
tissue into these constituents. The action of such remedies is very 
desirable in a vast number of cases; and even where the kidneys are 
diseased, these salts act favourably. 

A certain degree of dilution is necessary to ensure the diuretic 
action of many neutral salts. If the density of the solution be very 
great, exosmose of fluid from the blood will take place, and a pur- 
gative action will be produced. Certain salts may be made to act as 
purgatives or diuretics, according as they are diluted with a small or 
with a large quantity of water. The observations of Dr. Headland, 



64 EXCRETION OF 

however, show that this physical explanation cannot be applied in 
all cases. That sulphate of magnesia is absorbed into the blood, at 
least in the majority of instances, there can be no doubt. It is often 
excreted in large quantity in the urine ; and it is probable, as Dr. 
Headland suggests, that its purgative action is due to its removal, in 
the form of a weak solution, from the blood by the action of the 
intestinal mucous membrane. 

The excretion of urine will also be materially affected by all those 
circumstances which influence the circulation in the kidney. There 
exists a compensating action between the cutaneous secretory surface 
and the kidneys. If a large quantity of water escapes in the form of 
sweat, the urine will be small in amount and highly concentrated ; 
but if, from the effects of cold, there be scarcely any perspiration, the 
excess of fluid is entirely removed by the kidneys, and the solids of 
the urine are therefore held in solution in a much larger quantity of 
water. Pressure on the renal arteries, or on the aorta above their 
origin, will diminish the secretion of urine. Pressure on the veins, 
on the other hand, will first of all cause an increased flow of urine, 
and afterwards albumen will escape. In congestion of the liver and 
portal system, the amount of solids is greatly increased. It would 
appear that, in many cases, where the action of the liver is imperfect, 
and especially in some forms of organic disease, the kidneys, to some 
extent, perform the functions of the liver. In jaundice, both colour- ♦ 
ing matter and biliary acids are carried off in the urine. In this 
case, however, it must be borne in mind that these biliary con- 
stituents are formed by the liver, reabsorbed into the blood, and 
separated from it, as are many other substances abnormally present, 
by the kidney. In many affections of the liver, the urine-pigment 
is much increased ; and it is probable that a certain proportion of 
material which, in a state of health, would have been converted into 
bile, is transformed into certain extractive matters and other sub- 
stances, and eliminated in the urine. The crisis of many acute 
diseases is characterised by the presence of a large quantity of solid 
matter in the urine, and increased action of the kidney. Free 
sweating, and the secretion of a urine containing a large amount of 
urea and urates, in the course of many diseases, are often the earliest 
and most important indications of approaching convalescence. Dr. 
Golding Bird showed that abatement in the severity of the symptoms 
of ague was always associated with an increase in the amount of solid 



SUBSTANCES IN URINE. G5 

matter in the urine. Now, in all these cases, it is ohvious that the 
activity of the renal epithelium is increased. The separation of 
urinary constituents from the blood cannot be regarded as a mere 
percolation, but is dependent upon a vital property of the cells. It 
is probable that these cells take part in the actual formation of some 
of the urinary constituents, just as sebaceous matter is formed by the 
cells of the sebaceous glands, saliva by those of the salivary glands, 
&C. An alteration in the proportion of the water is rather to be 
attributed to temporary alteration in the calibre of the arteries which 
supply the Malpighian bodies, and to the variable pressure exerted 
by the blood as it traverses the Malpighian capillaries, depending, to 
some extent, upon the freedom with which it passes onwards into the 
capillary system, among the meshes of which the tubes lie. 

107. On the Absorption of Substances at the Stomach, and 
their Excretion in the TTrine. — The rapidity with which weak 
solutions are absorbed from the digestive organs, and secreted by the 
kidney, is marvellous. In Mr. Erichsen's well known experiments, 
it was shown that ferrocyanide of potassium could be detected in the 
urine within a minute after it had entered the empty stomach. 
These interesting conclusions were derived from experiments made 
on a case in which, from the deficiency of the anterior wall of the 
bladder and abdomen, the orifices of the ureters could be seen, and 
the urine collected as it trickled from them. A German suffering 
from this terrible malformation was in London in 1858, and many 
had an opportunity of seeing him, and observing how very soon, after 
a large quantity of water had been swallowed, the rate of the flow of 
urine from the ureters increased. 

Anything interfering with the absorption of fluid from the 
stomach or intestinal canal will necessarily affect the secretion of 
urine. In various cases where the contents of the alimentary canal 
are in a condition unfavourable for absorption, but a very small 
quantity of urine is formed. Dr. Barlow has gone so far as to say 
that the seat of an obstruction in the intestine can be ascertained by 
noticing the quantity of water excreted in the form of urine. When 
close to the pylorus, it is stated that scarcely any urine is separated. 
In ordinary cases of what is known as sick headache, where, from 
temporary stomach derangement, little absorption occurs for some 
hours, no urine is secreted perhaps for twelve hours or longer. The 



66 MORBID CHANGES 

termination of the attack is marked by the very free and rapid action 
of the kidneys. 

108. Morbid Changes aiEdotingr the Straotore of the Kidney. — 
In cases where the blood which passes through the kidney is un- 
healthy, the secreting power of the renal cells is gradually impaired. 

In cases of long continued wine and spirit drinking, this change 
probably results from an altered state of the blood engendered by 
the spirit, and not from its direct action, for there can be no doubt 
that large quantities of spirit may exist in the blood without 
producing any such change ; and in all cases in which renal disease 
results from spirit drinking, the kidneys are by no means the only 
organs affected. In many instances most of the tissues of the body 
suffer more or less from a general change which has resulted from 
alteration in the blood. In advanced cases the cells of renal epithe- 
lium lose their healthy appearance, sometimes becoming smaller and 
condensed, sometimes appearing granular, as if undergoing disinte- 
gration. In consequence of the growth of the germs having been 
interfered with at an early period, the place of the disintegrated cells 
is not occupied by a new generation. 

A complicated series of morbid changes in other structures of the 
kidney gradually ensues; and, in consequence of the blood being ren- 
dered still more depraved by the accumulation in it of matters which 
ought to be removed by the kidney, other organs suffer, and the 
changes continue to work on as it were in a circle. The coats of the 
smaller arteries become much thickened, the capillaries shrink, while 
their walls become thicker and often granular. The quantity of blood 
distributed to the organ diminishes; and many of the capillaries, 
being no longer required, shrink and cease to transmit blood. The 
diameter of the secreting tubes decreases, while the basement 
membrane is thickened and becomes more impervious. The whole 
organ becomes hard, and at the same time small and shrunken. 
This decrease in size takes place principally at the expense of the 
cortical or secreting portion of the kidney, as would be supposed. 
The Malpighian bodies waste. The remains of many may be seen 
without a capillary in them being pervious ; and not a few of those 
which still exist are found to be so altered that they can hardly be 
recognised as Malpighian bodies at all. The greater part of the 
blood sent to the kidney passes into the pyramids by the vasa recta, 



IN THE KIDNEY. 67 

and soon re-enters the veins, a small quantity being distributed to 
those tubes and Malpighian bodies nearest the pyramids. The 
diminished amount of urea, &c., present in the urine, is probably 
separated in this latter situation; while a certain quantity of water, 
with a little albumen and the material of which the casts are formed, 
also escape in this situation, as well as from the straight part of the 
tubes. 

But in such cases the vessels of the kidney are not the only vessels 
that are altered. The coats of the arteries of the body generally, are 
more or less altered. The smaller ones lose to a considerable extent 
their contractile power, and cease to be influenced by changes occur- 
ring in the nerves. Persons suffering from chronic renal disease, in an 
advanced stage, cannot blush. The calibre of the minute arteries is 
no longer affected by the nerves, and instantly altered by any mental 
emotion, as in health. 

Long before the disease has arrived at this stage, the urine will 
be found to contain a very small amount of solid matter, which 
consists principally of salts and extractives, with a very little urea. 

By many pathologists these changes are explained by the efiusion 
of inflammatory lymph, and subsequent thickening, condensation, 
and contraction of the so-called matrix ; but it seems to me that all 
the appearances observed may be much more simply accounted for, 
upon the view that they depend upon depraved nutrition and 
wasting, than by resorting to the hypothesis of the inflammation of a 
structure whose existence has not been satisfactorily demonstrated, 
and which, if it does exist, according to its warmest advocates, only 
serves as a supporting tissue to the more essential elements of the 
gland-structure. It is very hard to see why such a tissue, which 
takes no active part in the changes going on in the gland, should be 
the starting-point of all the serious morbid alterations which occur. 
The idea, I believe, has arisen from a supposed analogy between 
cirrhosis of the liver and the so-called chronic inflammatory disease 
of the kidney. Cirrhosis was considered to depend upon inflammation, 
thickening, and subsequent contraction of another supporting fibrous 
tissue (Glisson's capsule), which was supposed to surround the 
lobules of the liver, and by its contraction to press upon the vessels. 
("On Cirrhosis of the Liver," Archives of Medicine ^ Vol. L, p. 118.) 
For the origin of these morbid changes, we must look to the altered 
actions going on in the secreting structure, and not to inflammations 



68 A CASE OF ACUTE NEPHRITIS. 

of tissues of doubtful existence, which take no part in the nutritive 
operations or gland-functions. The conclusions to which I have 
arrived from my own observations, with reference to the nature of 
the so-called matrix in the healthy kidney, and the changes taking 
place in disease, are at variance with those usually entertained both 
in this country and on the continent. The discussion of this question 
involves the whole subject of areolar tissue and its corpuscles. For 
an admirable statement of the opinions generally held, with many 
original observations, I must refer to a work by Arnold Beer, lately 
published in Berlin {'^Die Binde-Substanz der Menschlichen Niere"), 
The drawings accompanying this work appear to me rather rough. 
The engraver, perhaps, has misinterpreted some of the author's 
representations. 

Acute Nephritis, — The changes which I have described and l&gured 
in the kidney, in a case of acute nephritis, are of the greatest general 
interest. The case occurred in the practice of Mr. Image, of Bury St. 
Edmunds. The patient was 33 years of age, and was operated on for 
strangulated hernia. Four days after the operation, erysipelas 
appeared, which subsided in the course of three days. The day after 
the erysipelas disappeared, the urine which had hitherto been healthy, 
was found to contain albumen, blood-casts and blood corpuscles. The 
man died nineteen days afterwards, the urine having been nearly sup- 
pressed for the last three days of his life. There was anasarca but 
no disturbance of sensory or motor power, and no vomiting. The 
casts in the urine, three days before death, are represented in Plate 
X., Fig. 51, and in Fig. 52 a portion of a cast is shown, magnified 
700 diameters. It contains in its central part, blood corpuscles and 
bodies like white blood corpuscles, which appear to be undergoing 
multiplication in the cast. The kidneys were much enlarged; one 
weighed 13 and the other 15 ounces. Now this considerable increase 
in weight was mainly due to the accumulation of matters in the 
capillary vessels and in the secreting tubes. The vessels were 
distended with large cells like white blood corpuscles (Plate X., Fig. 
53), and the tubes were filled with casts and cells like pus corpuscles. 
Now, there can be little doubt that the cells represented in Fig. 53, 
in the capillaries, have been formed from the white blood corpuscles, 
and it is almost certain that the pus-like corpuscles in the centre of 
the cast have the same origin. The whole organ was passing into a 
state of suppuration, and the pus-like corpuscles in the urine of this 



OAPJLLARIES OF THE KIDNEY-CASTS 
^g. 49. 



Plate x. 





f 103 



x4G3 



Pig. 51. 



§ § 105. 371 




Hg. 52. 






\ 



f 






\ "7" 






§ 108 



108 



To /ace page ^fe. 



bright's disease. 69 

case probably resulted from the multiplication of corpuscles in the 
tubes which were produced by the white blood corpuscles. (See 
'^Archives of Medicine^'' Vol. IL, p. 286.) 

Fatty degeneration. — In certain cases, the epithelium undergoes 
a very peculiar change, to which much attention has been given of 
late years. Fatty matter accumulates in the cells of the uriniferous 
tubes. The intertubular capillaries and those of the Malpighian 
bodies are also affected in a similar manner, and little collections of 
minute oil-globules may often be seen at intervals in their walls. 
This change often commences in a few of the tubes, and gradually 
extends until the whole organ is affected; but in some cases, only a 
few tubes here and there are affected by the disease, while many 
remain perfectly healthy. The kidney is in many instances much 
enlarged, while its colour has become very pale. Fatty degeneration, 
in many cases, is not confined to a single tissue or organ, but almost 
every part of the body is more or less involved. 

100. Brisrlit's Disease.— This term has been applied to all morbid 
conditions of tlie kidney associated with albuminous urine. Of late 
years, many important characters have been made out, by which we 
are enabled to distinguish several diseases of the kidney essentially 
different from each other — different in their origin, in their progress, 
and often in the results to which they lead. Dr. Johnson has accu- 
rately described several of these morbid changes, and his researches 
have been confirmed by other pathologists. However, some phy- 
sicians still insist that the different conditions above alluded to are 
merely different stages of one and the same morbid process. Let 
any one examine carefully the small contracted kidney so commonly 
found in the bodies of old drunkards, with its rough puckered surface 
and diminished cortical portion, and contrast it with the large, 
smooth, and pale kidney, in a state of fatty degeneration, which is 
not unfrequently met with in young people not more than twenty 
years of age. The causes of these diseases are different ; the con- 
ditions under which they occur are different; and although the 
result is fatal in both, death occurs in a very different way. Their 
chemical characters are different; their microscopical characters indi- 
cate the occurrence of changes which are totally distinct. Again, the 
treatment required in the early stages of these diseases, when alone 
any benefit is likely to be derived from treatment, is different. 



70 BENAL DISEASES. 

The divisions and nomenclature adopted by Dr. Jolinson are the 
following : Acute desquamative nephritis ; Chronic desquamative 
nephritis; Waxy degeneration of the kidney ; Non-desquamative 
disease of the kidney; Fatty degeneration of the kidney; Suppu- 
rative nephritis. Dr. Johnson still supports the same classification, 
and opposes the theory held by some pathologists with reference to 
the oneness of Bright's disease. He has recently written a paper on 
this subject, which will be found in VoL xlii. of the " Medico-Chirur- 
gioal Transactions" Dr. Johnson says, with regard to the oft 
debated question if large kidneys, at a subsequent stage of the 
morbid changes, contract, " The rule is, that a large Bright's kidney 
remains large to the end, and does not become a small one ; and, on 
the other hand, a contracted Bright's kidney does not pass through 
previous stage of enlargement." 



71 



CHAPTEE Y. 



Healthy Urine. General Characters — Note- Book — Conical 
Glasses for examining Urine — Quantify of Urine — Colour 
of Urine — Smell of Urine — Clearness or Turbidity — Con- 
sistence — Deposit — Specific Gravity — Methods of taking the 
Specific Gravity — Reaction — Add Urine — Alkaline Urine 
— Volatile and Fixed Alkali, 

In the present Chapter, the general characters of healthy urine, 
which are of the greatest interest in a clinical point of view, will he 
hriefly descrihed. It is very important that the observer should, at 
once, acquire the habit of recording the results of his examination ; 
and I therefore strongly recommend everyone to keep a note-booL 

110. Note-Book. — The result of every observation should be 
carefully entered in a note-booh at the time it is made; and it is 
often of the greatest importance to make a sketch of the micros- 
copical characters of a deposit, and to append a careful but short 
description of the specimen at the time the drawing is made, as well 
as notes of the case from which the urine was obtained. (On drawing 
and measuring objects, see "TA« Microscope in its Application to 
Practical Medicine" 2nd edit; refer also to § 33, and to Plate V., 
Pig. 22, of the present Work.) 

Now, suppose a specimen of urine brought for examination, how is 
the investigation to be commenced ? What are the first points which 
should attract notice? In what order should they be observed? And 
how is the nature of the constituents which are dissolved in the fluid, 
or which form a visible deposit, to be ascertained ? 

The perfectly fresh urine should be poured into a conical glass 
vessel (Plates I. and II., Figs. 6, 7, 9, § 12). If any deposit is 
formed, it must be subjected to examination in the microscope 



72 HEALTHY URINE. 

(Chapter III.), and certain chemical reagents must be applied, as 
described under the head of " Urinary Deposits." The chemical exa- 
mination of the fluid will be described after the general characters of 
healthy urine have been considered. 

111. dtiantity of Urine.— It is very important in all cases to 
know the quantity of urine passed in a given period of time. The 
most minute chemical and microscopical examination often fails to 
show any fact of importance in the investigation of a case, in con- 
sequence of the quantity of urine passed in the twenty-four hours 
not having been measured. The practitioner desires to know, not 
only the quantity of urine passed (that is, water and solid 
matter together), but in many cases it is necessary to be acquainted 
with the absolute amount of solid matter dissolved in the water. 
For this solid matter consists mainly of substances resulting from 
the disintegration of tissues and blood corpuscles. Such informa- 
tion can only be obtained by carefully measuring the entire quantity 
of urine passed in twenty-four hours, and evaporating a given amount 
of the mixed urines passed at different periods of the day to dryness. 
From the result obtained, the entire amount of solids passed can 
easily be calculated. 

The amount of urine and the proportion of solid matter it 
contains vary very much, from day to day, in healthy persons. The 
temperature of the air, and the amount of moisture present in it; 
the state of the skin and mucous surfaces generally; the activity of 
the functions of respiration and circulation; the amount of exercise; 
the quantity and nature of the food, and, of course, the amount of 
fluid taken — are some of the circumstances which affect the quantity 
of the urine passed. But the quantity of urine in health varies 
according to the size of the individual, or rather according to the 
weight and the activity of the nutritive changes, so that it is quite 
useless to put forward with confidence any definite amount as the 
average quantity of urine passed by individuals generally. The 
nature of the occupation also materially influences the amount passed. 
In round numbers, however, the proportion in health may be 
estimated at from twenty to sixty ounces; and a greater quantity is 
passed in the winter than during the summer months, because in cold 
weather less fluid escapes from the body through the skin. It is 
stated that rather more than two ounces of urine are secreted per 



COLOURING MATTERS. 73 

hour, but during some periods of the day the secretion is much more 
active than at others. 

112. Colour of TTiine. — Urine from the same individual varies 
much in colour at different times, and specimens taken from a num- 
ber of persons in a state of health exhibit the greatest variation in 
tint. Nevertheless, important information is often gained by observ- 
ing the colour of urine. In some cases, from the colour, we are led 
to suspect the presence of certain substances dissolved in the fluid ; 
in others, we may feel sure that certain morbid constituents are not 
present. The colour of the urine, as well as many other characters, 
seems to be affected by the period of the day, the nature of the diet, 
the state of the respiratory process, changes of temperature, and 
many other circumstances. Healthy urine varies from a pale straw 
colour to a brownish yellow tint. In disease, it may be perfectly 
colourless, of a natural colour, bright yellow, pinkish brown, of a 
smoky appearance, blood-red, or even dark blue. What we learn 
from these differences in colour will appear when we come to con- 
sider the characters of the urine in disease. Urinary deposits also 
vary much in colour : they may be white, pink, red, pale or dark 
brown, blue or black. 

The nature of the colouring matters of urine has been careftdly 
investigated by Heller, who obtained a yellow colouring matter, 
iiroa;antAt»— corresponding closely to vegetable indican. This sub- 
stance was also detected subsequently by Dr. Schunk, of Manchester. 
Prout had obtained indigo from urine, and had sublimed it in 1840. 
Uroxanthin can be decomposed by acids, or even by exposure to the air, 
into a red colouring matter, urrhodine; and a blue substance, uroglan- 
dne. The former has the same composition as indigo red; the latter, 
as indigo blue (Ci« Hg N 0,). Uroglaucine, analogous to the blue com- 
pound obtained from indigo, may be obtained from all specimens of 
urine, and, in disease, sometimes forms a visible blue deposit. Indigo 
blue has nearly the same chemical composition as hsematine : it is, 
doubtless, formed from it. Leucine, which has also been met with 
many times in urine, is another substance which may be produced in 
the formation of this blue deposit of indigo. The yellow colouring 
matter of healthy urine was termed by F. Simon, of Berlin, hcBina- 
phain. The presence of a substance in the urine from which indigo 
can be obtained must now be regarded as a settled fact ; and it is 

E 



74 UROXANTHIN. 

probable that the blue deposit observed in certain instances, and 
referred to by different authors, was indigo blue, formed by the 
decomposition of uroxanthin. Dr. Hassall has published some 
interesting cases, and has very carefully analysed the deposit (" Phi- 
losophical Transactions,^' 1854, p. 297; ^^Proceedings of the Royal 
Society" June 16th, 1853). I can fully confirm his statements, as I 
have recently had an opportunity of examining a specimen of urine 
with blue deposit, which was sent to me by my friend Dr. Eade, of 
Norwich.* In this case, the deposit was crystalline. 

Urotrythrine is another colouring matter described by Simon, 
and always associated with uric acid and urate of soda. This sub- 
stance is probably the roscusic acid and purpurate of ammonia of 
Prout, and the purpurine described by Dr. Golding Bird. It has 
been analysed by Scherer, who finds that it contains about 65 per 
cent, of carbon. It would seem that, when the elimination of sub- 
stances from the liver, rich in carbon, is interfered with, an increased 
quantity of this substance is excreted in the urine. A green colour 
has been noticed in certain cases (Parkes). Creosote and tar, when 
taken internally, sometimes cause the urine to be of a very dark 
colour. Dr. Harley finds that the colouring matter of healthy urine 
contains a notable quantity of iron, like the haBmatine of the blood ; 
and he gives to it the name of urohaematine. Prout believed that 
the colouring matter of urine was due to the presence of a sort of 
resin; and Dr. Harley has lately isolated a resinous substance, which 
possesses many characters in common with the resin derived from 
certain plants, and closely resembles draconine, which is obtained 
from dragon's blood, the exudation from the stem of one of the 
resin-bearing palms. 

The relation of the colouring matters of the urine to those of the 
bile has been dwelt upon, and Berzelius long ago drew attention to 
the resemblance of the latter to the chlorophyll of plants. Certain 
chemical reagents cause the same change in both these colouring 
matters. A red colouring material is not unfrequently seen in the 
cells in the central part of the lobules of the liver, and Dr. Bence 
Jones met with a gall-stone of a brick-red colour. There is much 
reason for believing that the formation of these colouring matters 
is connected with the disintegration of blood-corpuscles, and the 
quantity formed and the intensity of the colour probably depend 
• "ilrcWwi <^f Medicine,** Vol. L 



SMELL OF URINE. 75 

upon the activity of the oxidising processes going on in the organism ; 
but the whole question of the production of colouring matter in the 
living body is still involved in great obscurity. The separation of a 
substance from the urine, from which indigo blue and indigo red 
may be prepared, must be regarded as a fact of the greatest interest ; 
and further experiments on this subject are likely to lead to im- 
portant results in connexion with the formation of organic colouring 
matters in the animal body. {See also § 210.) 

113. Smell of Urine. — From the smell of the urine, in some 
instances, the practitioner may gain useful information. Healthy urine 
has a peculiar and very characteristic smell, which has been described 
as aromatic, but well known to all : it probably depends upon the 
presence of certain organic acids (Carbolic C^ He 0»), In disease, the 
specimen may be highly pungent, from the presence of carbonate of 
ammonia, which is produced by the decomposition of the urea excited 
by some animal ferment, especially by mucus of the bladder in a state 
of incipient decomposition. In other instances, it may have the smell 
of healthy urine, but the odour very much more intense. Sulphur- 
etted hydrogen may be evolved from it. The smell of the urine is 
affected by many articles of food, such as asparagus, garlic, and 
cubebs. Turpentine, even if inhaled, causes the urine to evolve an 
odour something like the smell of violets. 

114. Clearness of Turbidity. — Healthy urine is perfectly clear 
and transparent ; but, after it has been allowed to stand for a short 
time, a very faint, flocculent, bulky deposit collects towards the 
lower part of the vessel This cloud consists of a little mucus, with 
imperfectly formed epithelial cells from the mucous membrane, and 
epithelial (Ubris, 

In disease, the urine may be opaque, from the presence of 
different substances held in suspension. Urate of soda is the most 
frequent cause of this opacity, in which case the colour of the mass is 
generally of a dirty yellow, or brownish, resembling peas-soup. 
Very rarely it results from fatty matter in a minute state of division, 
and the urine has the appearance of milk. This occurs in cases of 
chylous urine. In these instances, the turbidity still continues after 
the urine has been allowed to stand still for some time; but generally 
the opacity of a specimen depends upon the presence of a deposit 
temporarily suspended in it from agitation, but which collects at the 

E 3 



76 SPECIFIC GRAVITY. 

bottom of the vessel after a time, forming a visible deposit, leaving a 
perfectly clear fluid above it. 

116. ConsistexiGe. — Healthy urine is perfectly limpid, like water, 
and can be readily made to drop from a tube. In disease, however, 
the urine may be slightly viscid, or so thick and glairy, or ropy, that 
it may be drawn up at the end of a rod like a thread, and cannot be 
made to drop at all. It may be semi-fluid ; and in rare instances, 
although passed perfectly fluid, it has afterwards assumed the form 
of a thick flrm jelly, so that the vessel containing it might be 
inverted without its escape. Such specimens have been met with, 
associated with a milk-like appearance, in cases of chylous urine, 

116. Deposit. — The only deposit which urine in health contains 
is the faint unimportant mucus-cloud before referred to (§ 114). All 
the constituents removed from the organism in this excretion, in 
health, escape in a perfectly soluble form; but when the healthy 
physiological changes are in any way interfered with, some of these 
constituents are produced in abnormal quantity, and are deposited, 
in an insoluble form, either at the time the urine is secreted, while 
it remains in the bladder, or at a variable interval of time after it 
has been passed. The deposit may be soluble in the warm fluid 
precipitated as soon as it becomes cold, or its deposition may be due 
to certain chemical decompositions occurring in the fluid. 

117. Speciflo Gravity: proportion of Solid Hatter. — By 
ascertaining the specific gravity of a specimen of urine (§ 23), we are 
enabled to form a rough estimate of the quantity of solid matter 
dissolved in the fluid; and, by measuring the entire quantity of 
urine passed in the twenty-four hours, we have data for judging 
approximately of the quantity of solid material removed from the 
organism in this secretion in twenty-four hours. 

The specific gravity of healthy urine may be considered to be 
about 1,015, and the quantity of solid matter passed in the twenty- 
four hours, amounts to from 800 to 1,000 grains. It has been 
considered suflScient to calculate the quantity of solid matter from 
the specific gravity, by multiplying the number over 1,000 indicating 
the specific gravity, by about 2*5. The result will give an approx- 
imation to the quantity of solid matter in 1,000 grains of urine. 
This calculation is by no means correct, and is useless for accurate 



REACTION. 77 

investigations. Its inexact nature is shown by the fact that three 
very different numbers have been proposed, namely, 5*58, 2*33 and 
1'65, When it is considered how widely different the composition 
of the solid matter may be in various specimens of healthy urine, it 
is obvious that results obtained in this manner must often be very 
wide of the truth. Take, for example, albumen and common salt. 
A fluid containing 136*4 grains of the former in 1,000 grains will 
have a specific gravity of 1,030; while one containing only 800 
grains of common salt in the same quantity will have a specific 
gravity of 1,064. The proportion of common salt in urine varies 
more than the other constituents, as it depends upon the quantity 
taken in the food. 

This clearly shows that any attempt to calculate the quantity of 
solid matter in an animal fluid cannot be very exact. In investi- 
gations, therefore, where any approach to accuracy is required, we 
must evaporate a given quantity of urine (1,000 grains) to dryness, 
at a low even temperature, and weigh the solid matter. As, however, 
this operation takes some time, physicians are compelled, as a general 
rale, to be content with taking the specific gravity. In many cases, 
the information gained by this simple operation is very important. 
Thus the urine may be not more than 1,002 or 1,003 — a condition 
commonly met with in hysteria. A patient may be continually 
passing urine of specific gravity 1,010 to 1,012, which is commonly 
the case with albuminous urine, passed by patients suffering from 
certain chronic kidney diseases. Urine, containing a very large 
quantity of urea, so much that crystals of nitrate of urea are formed 
upon the addition of nitric acid without previous concentration 
(excess of urea), usually reaches 1,030, or a little higher ; and in 
cases of confirmed diabetes, where very large quantities of sugar 
escape from the organism, the urine has a specific gravity of 1,035 
to 1,040, or even higher. 

118. Beaction. — The reaction of urine may be readily ascertained 
by the use of litmus-paper, which is prepared by soaking a thin but 
&m smooth paper in an infusion of litmus. It is desirable not to 
use blotting-paper, or any spongy form of paper, for this purpose. 
Urine, having an acid reaction, immediately reddens this blue paper. 
The alkaline reaction of urine is ascertained by the use of reddened 
Utmrn-paper, prepared by adding a very small quantity of dilute 



78 ACID URINE. 

acid to the infiision of litmus. An aJkali always restores the blue 
colour of this reddened paper. If no change occurs when the urine 
is tested with both kinds of paper, the reaction of the specimen is 
neutral, 

119. Acid Urine. — ^The cause of the acid reaction of urine is 
obscure, and probably does not always depend upon the presence 
of the same substance. Sometimes the reaction may depend upon 
carbonic a<ad, which is present in greater or less proportion in all 
the animal fluids. In this case, the blue colour of the paper is 
restored by gently warming it after it has been changed by the acid. 
A fixed acid reaction may be due to the presence of an acid phos- 
phate of soda — a salt which exhibits an acid reaction, without the 
presence of any free acid. This salt may be formed by the action of 
uric acid upon common rhombic phosphate of soda. If a little uric 
acid be added to a solution of common rhombic phosphate of soda, 
the mixture will, while cold, exhibit the characteristic alkaline 
reaction of the salt; but, when heat is applied, decomposition 
occurs; the uric acid disappears, and combines with one equivalent 
of the soda to form urate of soda ; and an acid phosphate of soda is 
produced (experiment). The acid reaction of urine, however, 
cannot always be explained in this manner ; and it is certain that 
traces of free organic acids are present. Lehmann has found both 
free lactic and free hippuric acids in some specimens of urine. 
Lately, Hallwachs has shown that a large amount of hippuric acid 
salts exists in healthy human urine. 

Many specimens of urine which are slightly acid when passed 
from the organism, become more strongly so after standing for some 
days, and crystals of uric acid are deposited. The acid reaction may 
remain for weeks or even months, but usually the acidity gradually 
diminishes, and the specimen at last becomes alkaline from the 
presence of carbonate of ammonia, formed in consequence of the 
decomposition of the urea. The researches of Scherer have proved 
that the gradually increasing intensity of the acid reaction, and the 
deposition of uric acid, were due to a process resembling fermen- 
tation, which was excited by the presence of a small quantity of 
mucus. 

The intensity of the acid reaction of urine in health is continually 
undergoing change at different periods of the day. Dr. Owen Eees, 



INFLUENCE OF DIGESTION. 79 

in 1851, stated that "the degree of the acidity of the urine may, to 
a certain extent, he regarded as a measure of the acidity of the 
stomach " (Lettsomian Lectures, " Medical Oazette^^ Vol. XL VIII., 
1851). Dr. Bence Jones has also made some highly interesting 
observations, which prove that the acidity of the urine alternates 
with that of the gastric juice. When the largest quantity of acid is 
being set free from the stomach, the acidity of the urine is at its 
minimum; and when the secretion of gastric juice is diminished, the 
mine exhibits a most strongly acid reaction. The urine passed just 
before each meal, or a long time after taking food, is intensely acid, 
while that which is secreted during the digestive process, for about 
three hours after a meal, is very slightly so, and in many instances 
it is decidedly alkaline. It is especially important to bear in mind 
the existence of these variations in the acidity of the urine in a state 
of health, and not to refer the intensely acid reaction of urine, 
secreted while no food is taken, to a morbid process requiring the 
exhibition of large doses of alkalies ("0« Animal Chemistry ^^ by H. 
Bence Jones, M.A., M.D., F.R.S.). Dr. Beneke has made upwards 
of one hundred experiments upon healthy and diseased persons 
without being able to confirm Dr. Bence Jones' observations. In 
only one case did he find the urine alkaline after meals. Sometimes 
the acidity was less, but this was not invariably the case, l^everthe- 
less, he admits that the acidity of the whole amount of urine passed 
varied considerably, although he could not discover the cause. It 
seemed to be independent of the quantity passed, and was not 
affected by exercise or food {^^Archiv des Vereins fur gemeinschaft- 
Uehe Arbeiten zur Fbrderung der wissensehaftlichen Heilkunde,^* 
I Band. 3 Heft.). Vogel, on the other hand, found that urine 
passed during the night was more acid than that secreted during 
the digestive process. Although the urine is by no means invari- 
ably alkaline, the acid reaction is always less intense after a meal. 
Dr. Roberts, of Manchester, has performed a very extensive series 
of experiments upon this question (" Memoirs of the Literary and 
Philosophical Society of Manchester" Vol. XV., 1859). He comes 
to the conclusion that, in two or three hours after a meal, the acidity 
of the urine is diminished, but that the secondary or remote effect of 
a meal is to increase the aridity of the urine. These results occur on 
an animal and also on a vegetable diet. Dr. Roberts considers that 
the above effects of the meal are due to the mineral constituents of 



80 ALKALINE URINE. 

the food, which contain alkali in excess of the phosphoric acid 
present. Hence arises the alkalinity of the Mood; hut if this 
increases heyond a certain point, the kidneys separate the excess, 
and the urine is alkaline. If, on the other hand, the blood is not 
sufficiently alkaline, the kidneys separate acid. Thus do these 
organs regulate the quantity of alkali in the blood. 

The intensity of the acid reaction is readily determined by ascer- 
taining how much of a graduated solution of carbonate of soda is 
required to neutralise the acid in a given quantity of urine. In 
stating the results, the degree of acidity is expressed as if it 
depended on oxalic acid. In twenty-four hours, a proportion of 
acid is excreted which corresponds to from 30 to 60 grains of crystal- 
lised oxalic acid, according to Vogel. 

120. Alkaline Urine.— The alkaline reaction of a specimen of 
urine may be due to the existence of carbonate of ammonia, in which 
case the blue colour produced by testing it with reddened litmus is 
destroyed by the application of a gentle heat {volatile alkali); or it 
may depend upon the presence of an alkaline carbonate, as carbonate 
of soda, or a neutral salt having an alkaline reaction, like common 
phosphate of soda, in which cases the application of heat does not 
restore the red colour of the litmus-paper {fixed alkali), 

121. Volatile Alkali.— The development of carbonate of ammonia 
in urine depends upon the decomposition of the urea by the action of 
the mucus or some animal matter, which acts the part of a ferment 
In some diseases of the mucous membrane of the bladder, and in 
cases of paraplegia, where the muscular coat of the organ is paralysed, 
and consequently the secretion is retained for a long time, this 
change is very liable to occur, and gives rise to pain and great 
distress, which are much relieved by washing out the bladder 
thoroughly with tepid water. A mere trace of urine which has 
undergone this change is capable of exciting a similar decomposition 
in a very large quantity. It is important to notice that if pus be 
present in such urine, it becomes coverted into a^ viscid glairy mass, 
which is removed from the bladder with the greatest difficulty. 
This action of the volatile alkali on the pus, precisely accords with 
that which occurs if ordinary liquor potassae be added to a specimen 
of pure pus out of the body. Pus thus rendered glairy, forming a 



VOLATILE AND FIXED ALKALL 81 

viscid adhesive mass at the bottom of the vessel containing the urine, 
is usually called mucus, but as I have said, it really consists of 
altered pus. If this action on the pus only occurs after the urine has 
left the bladder, it is unimportant, but when it occurs before its 
expulsion, it is always necessary to interfere, and if the change 
cannot be entirely prevented, owing to the existence of certain 
mechanical impediments to the escape of the urine, we must try to 
render the urine acid, and thus prevent its occurrence, by giving 
very large and frequently repeated doses of nitric acid, unless this 
treatment is contraindicated, as in certain cases which I shall have 
occasion to refer to. 

Whatever causes prolonged retention of the urine in the bladder, 
in the ureter, or pelvis of the kidney, will excite this change, and, 
as a consequence, roughening and ulceration of the mucous' mem- 
brane ensue, with the precipitation of phosphate of lime and 
ammoniaco-magnesian phosphate. More pus is formed, which 
effects the decomposition of the urea and aggravates the mischief 
already produced, and unless relief be afforded, complete disorgani- 
sation of the mucous membrane results. Volatile alkali is never 
detected in healthy urine. 

122. Fixed Alkali.— Urine, however, often exhibits an alkaline 
reaction due to the presence of an alkali which is not volatile by 
heat, and this reaction is often to be met with in a state of health. 
When an alkaline carbonate is detected in the urine, it usually 
results from the decomposition of salts of certain organic acids in 
the organism. Salts of tartaric, racemic, citric, and, under some 
circumstances, those of oxalic and acetic acids, become resolved into 
carbonates in their passage through the organism, just as by the 
influence of a red heat they are converted into carbonates out of 
the body. The urine may always be rendered alkaline, and very 
quickly so, by giving such salts in sufiicient quantity; and their 
administration is of great advantage in cases where benefit is likely 
to be derived from alkalies, especially where strong alkalies do not 
agree with the digestive organs. I believe that in many cases the 
alkali thus formed in the organism exerts a more beneficial influence 
than the exhibition of alkalies or their carbonates. The value of the 
juice of oranges and lemons in various conditions is to be attributed 
to this change. 

E 5 



82 ALKALINE URIKE. 

If the alkaline reaction of the urine is due to the presence of 
carbonate of ammonia crystals of triple phosphate (" lUustrations^^^ 
Plate IX., Fig. 1; XXI., Figs. 1, 3), and a deposit of phosphate 
of lime in a granular state, or in the form of globules or minute 
dumb-bells, will be present; if, on the other hand, it depends upon 
fixed alkali, only the latter deposit without the crystals will be 
detected. 

The quantity of alkali can be estimated by the ordinary process 
of alkalimitry. Dilute sulphuric acid containing a known quantity 
of pure sulphuric acid is added until the reaction is neutral to test 
paper. 

Before resorting to a more complete chemical and microscopical 
examination of a specimen of urine, it is important to ascertain the 
quantity passed in twenty-four hours, to notice its colour, smell, 
consistence, clearness, or turbidity^ and the presence or absence of a 
deposit, and to ascertain its specific gravity and reaction. 



83 



CHAPTER VI. 



Healthy Urine. I. Volatile Consiituenis. — II. Organic Consti- 
tuents. — ^III. Inorganic Constituents — Volatile Constituents: 
Water — Carbonic Acid — Ammonia and Ammoniacal Salts. 
Organic Constituents: Urea — Quantity — Characters — 
Circumstances affecting the Formation of Urea — Origin — 
Creatine — Creatinine — Guanine — Sarcine — Inosite — Uric 
Acid — Quantity — Detection — Mode of Formation — Urates 
— Hippuric Acid — Extractive Matters — Stdphur Compounds 
— Sugar — Mucus— ^ Lactic Acid and Lactates — Oxalic Acid 
— Peculiar Organic Acids and Formic Acid. 

It is convenient to divide the constituents of healthy urine into 
three classes, viz.: — 

I. Volatile Constituents; 
II. Organic Constituents; 
III. Inorganic Constituents. 

The first class includes those substances which are volatilised 
at the temperature of a steam-bath (212° or less). The most 
important of these are, water ^ carbonic acid, and certain ammoniacal 
salts. 

The second class contains those organic constituents which are 
not volatilised at a temperature of 212°, but which are decomposed 
at a red heat. The most important of these are, urea, uric or lithic 
acid, hippuric acid, with urates and hippurates, lactic add and 
lactates, mucus from the bladder or other parts of the urinary 
mucous membrane; creatine, creatinine, and various indeterminate 
uncrystallisable substances included under the head of extractive 
masters. The colouring matters already described (§ 112), and certain 



84 VOLATILE CONSTITUENTS. 

peculiar organic acids, traces of sugar ^ with perhaps traces of leucine, 
tyrocine, and one or two other less important organic matters, might 
be included in this class. 

In the third class are found various saline matters which 
remain fixed after the organic matter has been destroyed by a red 
heat, and the carbon which results, removed by prolonged exposure 
to a dull red heat in contact with the air. These inorganic con- 
stituents consist principally of chlorine, sulphuric and phosphoric 
avoids, and, in some cases, nitric add, in combination with sodium, 
potash, soda, lime, magnesia, iron, and sometimes alumina, with 
traces of silica, 

I. Volatile Constituents op Healthy Ueinb. 

123. Water.— Healthy urine contains from 940 to 960 grains, or 
even more, in 1,000. The proportion of water is much influenced 
by various circumstances, especially by the quantity taken in the 
food, the activity of the skin, and the presence of various substances 
which influence the chemical changes going on in the tissues, or 
affect the secreting action of the kidneys. The mode of estimating 
the proportion of water has been before alluded to. At first this 
would be supposed to be a very simple matter, but in practice it is 
found to be one of the most difficult operations in analysis, because 
many of the organic constituents of urine are prone to undergo 
changes at a very moderate heat, and even at the temperature of the 
air, if the concentration is effected too slowly. Practically, it is the 
best plan to concentrate the urine at a temperature of 100°, and then 
continue the evaporation in vacuo over sulphuric acid until the 
residue ceases to lose weight (§ 10). 

124. Carbonic Add is held in solution in fresh urine : indeed, 
traces may be detected in all the animal fluids. Its presence may be 
shown by passing some pure hydrogen gas through urine. After the 
gas has traversed the urine, it should be conducted into pure lime 
water, which will become turbid if there be an appreciable quantity 
of carbonic acid present. This experiment is founded upon the feet 
that, if one gas be passed through a solution of another gas, the latter 
will be displaced by it. By distillation, also, the presence of carbonic 
acid may be shown ; but, in this process, great care must be taken 



AMMONIA. 85 

to prevent the production of carbonate of ammonia, which would, of 
course, cause a precipitation of carbonate in lime or baryta water. 
The fluid may be made to boil at a temperature of 120, if the air be 
exhausted. There are certain peculiar volatile acids which will be 
described with the other acids of the urine (§ 150). 

126. Ammonia and Ammoniacal Salts.— Another volatile 
constituent of urine is ammonia. The presence of this substance 
in healthy urine has been doubted by many; but Heintz has shown 
that the addition of chloride of platinum to fresh urine causes a 
precipitate which consists of the potassio-chloride of platinum, 
with a certain quantity of the ammonio-chloride of platinum ; the 
amount of the latter being estimated by determining the quantity 
of the potassio-chloride in a separate experiment. Neubauer has 
obtained thirteen grains of ammonia from the urine in twenty-four 
hours. Ammonia exists as urate and lactate ; it is also found in 
combination with hydrochloric acid, with phosphoric acid and soda, 
and with phosphoric acid and magnesia. Chloride of ammonium 
is also present. Neubauer and Kemer estimate the quantity of 
chloride of ammonium at about 35 grains in twenty-four hours. 

Ammonia is likewise given off" during the decomposition of 
several of the organic constituents of the urine by heat, as indeed 
it is from many other nitrogenous organic substances. Thus, if a 
portion of the solid residue of urine be exposed to a temperature 
short of redness in a small glass tube, much very offensive vapour 
will be given off, and a carbonaceous residue will remain in the 
tube. ' If a piece of reddened litmus or turmeric paper, moistened 
with distilled water, be applied to the mouth of the tube as soon as 
it is heated, the blue colour of the former will be restored, and the 
latter will assume a dark brown tint — reactions which indicate the 
existence of volatile alkali or ammonia, which arises from the 
decomposition of nitrogenous matters. 

II. Organic Constituents op Healthy Urine. 

Many of the constituents of healthy urine may be obtained in a 
crystalline form by allowing a few drops to evaporate, at a moderate 
temperature (about 140°), upon a glass slide, or in a shallow oval 
glass cell. In this manner, crystals of urea, urate of soda, chloride 
of sodium crystallised in cubes and octohedra, phosphates, and sul- 



86 UREA. 

phates, may be readily obt-ained. The observer should make himself 
familiar with the appearance of these crystals. {^^Illustrations of 
Urine" etc. ; Urine, Plate I.) 

The quantity of the organic constituents varies very much, as 
would be supposed. In healthy urine, about three-fourths of the 
solid matter consists of organic substances, and there may be found 
from 12 or 14, to 45 or 50 grains in 1,000 grains of urine. The 
mode of estimating the amount of solids has been already referred 
to (§§ 123, 10). The quantity of the organic constituents is easily 
obtained by burning a weighed portion of the solid matter, and by 
subtracting from the amount the quantity of saline residue which 
remains after incineration. The result gives the quantity of organic 
matter. 

126. Urea (Gg H« Oa Na).— The most important of the organic 
constituents of urine is urea. It is a crystalline substance, veiy 
soluble in hot water, and in four or five parts of cold water, soluble 
in alcohol, but insoluble in pure ether, deliquescent, readily crys- 
tallised if pure, but the presence of some organic constituents 
seriously interferes with its crystallisation. However, good crystals 
of urea may often be obtained by simply evaporating a specimen of 
urine upon a glass slide, at a moderate temperature. Urea has a 
cool saline taste, is perfectly colourless when pure, but has a very 
strong affinity for the colouring matter of urine. In order to obtain 
perfectly colourless urea from urine, it is necessary to expose it to 
the prolonged action of animal charcoal in a diluted state. 

127. Quantity.— Urine in health contains from 12 or 15 to 30 
or 40 parts of urea per 1,000; and as much as from 400 to 600 
grains of solid urea are excreted from the body of a strong healthy 
man in twenty-four hours. The solid matter of healthy urine 
contains half its weight of pure urea. The amount of urea excreted 
in twenty-four hours, corresponding to each pound weight of the 
body, is about 3'5 grains. So that a healthy man, weighing about 
140 lbs., ought to secrete during the twenty-four hours nearly 500 
grains of urea. In infants and children, however, a much larger 
quantity in proportion to the weight of the body is secreted. From 
some calculations of Dr. Farkes, based on analyses made by Scherer, 
Rummell, Bischoff, and Lecanu, it appears that a child, weighing 



TESTS FOR UREA. 87 

about 30 lbs., and four years of age, will excrete for each pound 
weight of the body nearly 6 grains of urea in twenty-four hours. 

The Rev. S. Haughton (a paper read before the Association of 
the King and Queen's College of Physicians, Dublin, 1860) has 
endeavoured to show that of the urea excreted certain proportions 
represent the vital, mechanical^ and mental work performed in the 
organism. Men employed in ordinary routine bodily labour may 
be well fed on a vegetable diet, and discharge 400 grains of urea 
daily, of which 300 grains are spent in vital, and 100 grains in 
mechanical work. If the work is of a higher order, better food must 
be supplied, and 533 grains of urea are excreted. Of this quantity 
300 grains are spent in vital, and 233 grains in mental work and 
the mechanical work necessary to keep the body in health. 

128. Detection. — Nitrate of Urea. — The presence of ^ urea is 
very easily detected, if the solution be moderately strong. If a 
few drops of strong nitric acid be added to urine which has been 
slightly concentrated by evaporation, and afterwards allowed to cool, 
a number of beautiful sparkling crystalline lamellsB immediately 
make their appearance. These crystals of nitrate of urea are not 
very soluble in the solution, and are easily recognised by their 
microscopical characters (Plate XI., Fig. 55), {^^Illustrations of 
Unner Plate III.) 

Oxalate of Urea, — If, instead of nitric acid, a concentrated 
solution of crystals of oxalic acid be added to the concentrated 
urine, numerous crystals of oxalate of urea would be formed. The 
oxalate is also a very insoluble salt, and, like the nitrate, crystal- 
lises in rhomboidal plates; but the crystals are more perfectly 
formed, and the inclination of the angles is different (Plate XI., 
Fig. 66). {''Illustrations of Urine," Plate IV.) 

A solution of pemitrate of mercury also forms a precipitate with 
urea ; but, in order to apply this test, all the chloride of sodium and 
phosphates must be removed. Liebig has proposed a most simple 
and highly efl&cacious plan for estimating the quantity of urea by 
ascertaining the amount of a solution of pemitrate of mercury, of 
known strength, which is required to throw down the whole of the 
urea in a given volume of urine. This process for estimating the 
quantity of urea, as well as the simple plan proposed by Dr. Davy, 
has been described in § 39. Other plans of estimating urea have 



88 CIRCUMSTANCES AFFECTINQ 

been proposed, but they are more complicated than those already 
described. Urea in solution is decomposed by nitrico-nitric acid, 
carbonic acid being rapidly given off". Draper's process is founded 
upon this fact (" Phil Mag.;' Vol. VI., Series IV., p. 290). Bunsen 
and Ragski have recommended other methods based upon the decom- 
position of urea into carbonate of ammonia. By ascertaining the 
quantity of carbonic acid or of ammonia formed, the proportion of 
urea can be calculated (" Quarterly Journal of Chemical Science" 
Vol. I., p. 420). 

129. Characters. — Urea crystallises in four-sided prisms, which 
seem to be composed of a number of acicular crystals (Plate XL, Fig. 
64). {^^Illustrations of Urine,'' <fcc., Plate II., p. 56.) It melts at 
248°, and is decomposed at a higher temperature; cyanate of ammo- 
nia and carbonate of ammonia being among the products of the 
decomposition. It is not decomposed by being boiled in pure water, 
but mere traces of putrescent animal substances excite rapid decom- 
position even in the cold. Yeast also exerts the same effect; and 
mucus and pus produce this decomposition very rapidly, as already 
remarked under the head of "volatile alkali" (§ 121). The rapid 
evolution of carbonate of ammonia from urine which has been placed 
in a dirty vessel, is explained in the same manner. 

It is curious that urea causes common salt, which, under ordinary 
circumstances, crystallises in cubes, to crystallise in octohedra; and 
chloride of ammonium, which crystallises in octohedra, to crystallise 
in cubes. 

In the laboratory, urea may be formed artificially. By allowing 
cyanate of ammonia to evaporate to dryness, it becomes converted 
into urea, in which neither cyanic acid nor ammonia can be detected. 
Urea is one of the products formed by the action of peroxide of lead 
on uric acid, and it is also produced by the action of alkalies upon 
alloxan and creatine. B6champ stated that he had obtained urea 
directly from the action of oxidising substances on protein com- 
pounds, as permanganate of potash upon albumen. This experiment 
has been many times tried in my laboratory without success, and 
several chemists have failed to confirm B6champ's results ; so that 
we may consider that, up to the present time, no one has succeeded 
in producing urea directly from the tissues, or from albuminous 
substances. 



URE^. URJC ACID. HIPPURIC 



Pig. 54. 




§ 126 




§ § 128, 203 



2J5 



Pifif. 67. 



»> 



&v'D<> 




>< 216 



r?^ 



§§ 134, 321 



S 140 



To/accpage%% 



THE FORMATION OF UREA. 89 

If it is desired to obtain a specimen of pure urea from urine, 
an oxalate or nitrate is first prepared, purified by being recrys- 
tallised, dissolved in water, and heated for some time in contact 
with pure animal charcoal. When the solution is colourless, it is 
decomposed with chalk or carbonate of barytes. The urea is sepa- 
rated by alcohol, and the solution concentrated, so that crystals 
may form. The pure crystals are very deliquescent ; but they may 
be dried and preserved for any length of time, if careMly excluded 
from the air. They form beautiful microscopic objects. 

Rich in nitrogen, very soluble in water, readily difiused through 
large quantities of fluid, and possessing considerable power of per- 
meating animal membrane, urea may be regarded as the principal 
product resulting from the disintegration of nitrogenous tissues, 
(probably immediately from the red blood corpuscles), and as one of 
the most important excrementitious substances from the animal 
organism. Not only is urea derived from the products resulting from 
the disintegration of muscular fibre, but any excess of albuminous 
materials taken in the food is removed from the body chiefly in the 
form of urea. It must, however, be borne in mind, that the urea 
does not exist in the fluid expressed from the muscles: it is pro- 
bably formed in the blood. 

130. Circumstances ajffectiner the Formation of Urea. — The 
quantity and nature of the food, and all circumstances which afiect 
the nutrition and repair of the tissues, will exert an influence upon 
the quantity of urea formed in a given time. A liberal diet, rich in 
albuminous substances, and active exercise, combined with a healthy 
state of the organs of respiration and circulation, cause the formation 
of a large quantity of urea; while indolent habits, a diet rich in 
carbon and poor in nitrogen, insufficient food of any kind, an 
unhealthy state of the lungs and circulatory organs, and an imperfect 
supply of good air, will diminish the proportion formed. It need 
hardly be said that a greater quantity of urea is formed during the 
day than during sleep; by strong muscular persons, than by weak 
ones; by men than by women; in winter, when a small quantity of 
excrementitious substances are removed by the skin, than in summer, 
when the perspiration is abundant. 

In all probability, urea is formed in the organism by the 
oxidation of uric acid and other substances. If the oxidising 



90 QUANTITY OF UREA. 

processes in the body are active, these substances become ultimately 
resolved into urea and carbonic acid; but if, on the other hand, these 
processes are less active than they should be, the uric acid does not 
undergo further decomposition. A certain quantity of oxalic acid, 
and other substances of a lower degree of oxidation than urea, seem 
to be produced, and instead of the greater part of the comparatively 
insoluble uric acid being resolved into soluble urea, an increased 
quantity is found in the urine. Wohler and Frerichs have shown 
that, if uric acid be taken at night, oxalate of lime is found in the 
morning urine; and Neubauer found that, when rabbits were made 
to take a considerable quantity of uric acid with their food, the urea 
in their urine increased from 1*34 to 4 grammes (from 20*67 to 61*72 
grains). Large quantities of fluids cause an increase in the proportion 
of urea formed in the organism. A dilute state of the solids is 
favourable to their oxidation; and in certain conditions, where these 
changes are but imperfectly carried on, and in consequence uric acid 
accumulates in the blood, or at most is resolved into oxalic acid, the 
further oxidation is promoted by the administration of increased 
quantity of fluid, especially of fluids containing alkalies which not 
only increase the activity of the changes, but effect the solution of 
the insoluble uric acid and urates. Hence the benefit of alkaline 
waters, baths, moderate exercise, and plenty of good air, in gout and 
other conditions in which much more uric acid is formed than can 
be, under ordinary circumstances, converted into urea. 

The quantity of urea excreted is also increased by common salt 
(Bischoff ). It is probable that not only does cloride of sodium, so to 
say, filter through the different tissues, like other saline substances, 
and thus drive out other materials which are contained in their 
interstices; but that it also facilitates the occurrence of chemical 
change in the body, and directly influences the quantity of urea 
formed. The importance of chloride of sodium in cell-growth, during 
the development of different textures, and its value in nutrition 
generally, are well known. 

The beneficial effect of alkalies in different cases is acknowledged 
by all; and it is probable that this is in part to be explained by the 
influence they have been proved to possess in promoting chemical 
change in the body, and especially in favouring the oiddation of 
albuminous substances. Dr. Parkes has shown conclusively, in an 
elaborate series of experiments, that liquor potassse exerts a direct 



EFFECTS OF ALKALIES. 91 

influence of this kind. ("On the Action of Liquor PotasssB on the 
Urine in Health," British and Foreign Medico-Chirurgical Review, 
Vol. XIV., p. 258, January, 1853.) The per centage of solids in the 
urine is increased, the urea seemed to be increased somewhat; but 
Dr. Parkes considers this only a probable effect of the alkali. The 
proportion of sulphates was augmented in all the experiments. 
Franz Simon long ago showed that the sulphates were always 
increased whenever an increased proportion of urea is formed ; and 
the more recent researches of Dr. Bence Jones lead to the same 
conclusion. In Dr. Parkes' experiments, the acidity of the urine 
was hardly affected by the liquor potassaB ; and the whole of the 
potash taken (2 drachms) was entirely excreted in the urine, in the 
form of sulphate, in a very short time, — if taken on an empty stomach, 
in from thirty to ninety minutes. Such facts assist in the most 
important degree to elucidate some of the most complicated chemical 
changes going on in the organism, and afford valuable information 
as to the nature of various morbid changes, as well as suggest the 
means by which these may be modified or counteracted. For these 
reasons, I have thought it desirable to dwell upon them rather 
at length. 

On the other hand, both the solids (urea, extractives, uric acid, 
sulphuric acid by 13 grains, daily phosphoric acid, chloride of sodium 
very considerably), and fluid of the urine are diminished by alcohol; 
so also is the proportion of carbonic acid exhaled. Tea causes a 
diminution both in the quantity of urine and faeces, as the beautiful 
researches of Dr. Bocker have conclusively proved. ("Beitrage zur 
Heilkunde Vol. I.," Medico - Chirurgieal Review, Vol. XIV.) 
Hammond's observations confirm Booker's in the most important 
particulars {^^ American Journal, Medical Science,^^ October, 1856). 
Coffee exerts a similar effect, which seems to be due, not to the 
caffeine, but to the empyreumatic oil which it contains, according to 
Julius Lehmann. These substances, tea, coffee, and alcohol, in 
moderate quantity, affect the disintegration of tissue, and directly 
diminish the quantity of the excrementitious substances formed in 
the process. Supposing the food to be insuflficient, the loss of weight 
which must necessarily take place in the body would be lessoned; 
and they may, therefore, be regarded as advantageous, not only in 
economising the food, but in limiting to some extent the waste of the 
albuminous tissues. Probably these substances directly interfere with 
the disintegration of the blood corpuscles. 



92 ORIGIN OF UREA. 

181. Orifirin.— It has been concluded that urea is not formed in 
the kidneys, as it has been shown to exist in the blood. It is merely 
selected or separated from this fluid by the cells of the uriniferous 
tubes. At the same time it must be admitted^ that it has not been 
proved, that no urea whatever is found in the kidneys. It is with 
difficulty detected in healthy blood, because it is prevented from 
accumulating in that fluid in sufficient quantity by the selective 
power of the renal epithelium.* If, however, the secreting action of 
the kidneys be impaired by disease, or if the blood be prevented from 
flowing through them, the urea will accumulate in the blood to a 
considerable extent, interfering with the function of other organs, 
especially the brain; and may in many cases be very readily detected 
by chemical tests. 

Under these circumstances, an incomplete removal of the urea 
will take place through other channels. It has been detected in the 
fluids of the intestinal canal, in vomited matters, in the saliva, tears, 
milk, bile, and sweat, in serous fluids in different localities, in the 
liquor amnii, and in the fluids of the eye. 

Urea cannot be detected in the muscles, but can be readily pro- 
duced from several substances found in them; and it is therefore 
probable that, in the organism, urea forms the last of a series of 
compounds which results from the disintegration of the tissues, or 
more immediately from the disintegration of blood corpuscles. 
Removed from the body, very slight causes are capable of effecting 
its decomposition, and resolving it into ammonia and carbonic acid 
— substances of the highest importance to the growth of plants. 

It has been generally concluded that any albuminous matters 
taken in the food, in excess of what is required for the nutrition of 
the system, is at once converted into urea. Bischoff and Voit have 
endeavoured to show, on the other hand, that in this and in all cases 
the urea results from tissue metamorphosis. It seems to me most 
probable that all pabulum entering the system must, before its 
elements can be applied to the nutrition of the tissues or be removed 
by the organs of respiration and secretion, be first of all taken up by 
cells (chyle corpuscles, white blood corpuscles), and become living 
or germinal matter, which, after passing through certain definite 

* Dr. Thudichum attributes the failures of observers to detect urea in the blood, to 
their precipitating the albumen by heat. If the blood be treated with strong alcohol, 
the urea is dissolved, and the albumen rendered insoluble at the same moment The 
former can be detected in the alcoholic solution. 



CREATINE. 93 

stages of existence, becomes the formed matter of the red blood 
corpuscles. The products resulting from the disintegration of this 
formed matter may be taken up by the germinal matter of tissues, 
and at length become tissue, or by that of secreting cells, in which 
case it is removed from the body altogether. 

182. Creatine (C8H0N3O4) exists in small quantity in urine. 
Its presence in this secretion was discovered by Heintz. Dr. Thudi- 
chum has obtained from 3*45 to 6*32 grains of creatine from the 
urine of a healthy man in twenty-four hours. The average is 4*7 
grains. Creatine has a pungent taste, is very soluble in hot water, 
but requires about seventy-five parts of cold water for its solution. 
It is very slightly soluble in alcohol, and quite insoluble in ether. 
It crystallises in right rectangular prisms and rhomboidal crystals. 
{*' Illustrations of Urines'' Plate VII., Fig. 3.) By being boiled with 
baryta water, it is converted into urea and sarcosine ; with strong 
acids, into creatinine. 

Creatine may be obtained from urine by the following process, 
proposed by Liebig. Lime water and chloride of calcium are first 
added to the urine, which is then filtered and concentrated by 
evaporation, in order to remove most of the salts. The liquid from 
which the salts have been separated is decomposed with one-twenty- 
fourth of its weight of a syrupy solution of chloride of zinc. After 
the lapse of some days, a number of round granules made their 
appearance. These consist of chloride of zinc and creatinine, with 
which creatine is mixed. (^^Illustrations of Urine,-' Plate VII., 
Figs. 1 and 2.) They are dissolved in hot water, and treated with 
hydrated oxide of lead until the reaction is alkaline. The oxide of 
zinc and chloride of lead are to be removed by filtration ; and, after 
being decolorised by animal charcoal, the solution is evaporated to 
dryness. The residue is to be treated with boiling alcohol, which 
dissolves the creatinine very readily, but leaves the creatine, which 
may be recrystallised by solution in hot water. Crystals of creatine 
are represented in Plate XL, Fig. 59. 

Creatine is obtained from all kinds of lean meat, but exists in 
larger proportion in that of mammalia than in birds, reptiles, and 
fishes. Gregory obtained -14 from 100 parts of bullocks' heart, '08 
in 100 parts of pigeons' flesh, and 0*6 in the same quantity of the 
flesh of the skate. Although the flesh of fishes contains less creatine 



94 CREATININE. GUANINE. 

than that of the higher animals, it is more favourable for extraction. 
I obtained more than seventeen grains of creatine from two pounds 
of the flesh of the crocodile. The presence of creatine has been 
detected in the blood by Verdeil and Marcet. Traces of it have 
been discovered in the amniotic fluid. 

Its existence in the juice of muscular tissue, and its presence in 
the urine, would lead to the conclusion that creatine was one of the 
nitrogenised products resulting from the disintegration of muscular 
tissue; and such a view of its nature is supported by the readiness 
with which it is decomposed into urea, creatinine, and sarcosine. It 
is found in greater quantity in muscles which have been in active 
exercise during life, than in those which have been quiescent. The 
heart yields a large quantity ; and more is found in animals which 
have been hunted to death than in those destroyed without being 
subjected to violent exercise. Creatine may, like urea, be regarded 
as an excrementitious substance. 

133. Creatinine (GgH^KaOa) is also crystalline. The crystals 
take the form of right rectangular prisms, according to Robin and 
Verdeil. It has a strongly alkaline reaction, and is soluble in water. 
It is very soluble in warm alcohol. It combines with different acids 
to form salts. With chloride of zinc a crystalline compound is 
formed, composed of roundish wart-like masses, made up of minute 
radiating crystals, which have been already referred to. 

Creatinine is found in the urine in larger proportion than 
creatine, and must be considered as an excrementitious substance. 
It is not destroyed in the decomposition of urine, while the creatine 
undergoes conversion into creatinine. Dr. Thudichum obtained as 
much as from five-and-a-half to nearly ten grains of creatinine from 
the urine of a healthy man in twenty-four hours. 

134. Guanin* (Ci^JSifii), Saroine, Inosite (C^J)^ + 4Aq^,),— 
Strahl and Liebdrkiihn have discovered a substance in urine which 
they considered to be xanthine, but which, from its behaviour with 
reagents, may probably be regarded as guanine. Strecker has 
detected in urine a substance closely resembling sarcine, found in 
muscular fibre ; but its exact nature is at present doubtful. Inosite 
has been found in the urine of a man suffering from Bright*s disease 
by Cloetta, but it has not yet been detected in healthy urine. 
Crystals of inosite are represented in Plate XI., Fig. 60. 



URIC OR LITHIC ACID. 95 

185. Urio or Lithic Add (CxoHiK^Oe).— The organic constituent 
of the urine which ranks next in importance to urea is uric or lithic 
acid. In healthy urine its presence cannot be detected, unless a 
small quantity of a stronger acid, as nitric or hydrochloric, be first 
added to decompose the soluble urates. After the mixture has been 
allowed to stand for some time, the uric acid separates in the form 
of small red crystalline grains, which adhere to the sides of the 
glass vessel. Upon microscopical examination, these are found 
sometimes to be composed of separate crystals, and sometimes of 
small stellate groups ; the individual crystals varying in form from 
the lozenge-shape to that of an elongated crystal with sharply 
pointed extremities. {^^ lUustratione,^' Plate IV., Figs. 2, 3, 4, and 
6.) Uric acid is a very weak acid, and is perfectly separated from its 
salts by acetic acid. It is soluble in solutions of alkaline lactates, 
acetates, carbonates, phosphates, and borates. Uric acid has the 
power of decomposing the alkaline phosphates. It takes a part of 
the base, forming a urate, and leaves an acid phosphate, as I men- 
tioned when speaking of the acid reaction of urine. The colour of 
the crystals of uric acid which have been obtained from urine is 
derived from the proper colouring matters of the secretion, and 
must, therefore, be regarded as an impurity. It can easily be 
obtained perfectly pure and colourless ; and, in three or four 
instances, I have observed perfectly colourless crystals of this sub- 
stance, which have separated spontaneously from urine holding in 
solution scarcely a trace of colouring matter. 

Pure uric acid crystallises in the form of very thin rhomboidal 
laminae; but the sides of the crystals, instead of being perfectly 
straight, are usually more or less curved. The angles, again, are often 
rounded, so that the crystal has an oval form. In Plate IV., Figs. 2 
and 6, and Plate V., Fig. 7, of the '' Illustrations,''* some pure crystals 
of uric acid are represented. Some of these crystals were obtained 
by the addition of acid to the solution. Although uric acid may be 
perfectly pure, the crystals vary much in size and form (Plate XL, 
Pig. 57). Experiments show what very slight variations in the 
conditions under which they are produced are sufficient to determine 
great alterations in the form of the crystal. 

136. Quantity.— Healthy urine contains from half a grain to a 
grain of uric acid in 1,000 grains of urine. The solid matter contains 



yb TESTS FOR URIC ACID. 

about 1'3 per cent, of this substance, and probably from five to eight 
grains are excreted by a healthy adult man in twenty-four hours. 
Dr. Thudichum gives the latter as the average quantity. The 
quantity of uric acid excreted in twenty-four hours, for every pound 
weight of the body, amounts to "059, according to Parkes. 

187. Deteotion.--The chemical characters of uric acid are well 
marked. 

1. If to a deposit consisting of uric acid, placed on a glass slide, 
a drop of nitric acid be added, a brisk effervescence ensues; and when 
the mixture is slowly evaporated over a lamp, a reddish residue is 
left. Upon the addition of a drop of ammonia, a rich purple tint is 
produced, owing to the formation of mureidde, the so called purpurate 
of ammonia. This test is exceedingly delicate : it was first applied 
by Dr. Prout. One other substance possesses a similar reaction, and 
this is caffeine ; but uric acid is at once distinguished from it by its 
microscopical characters. 

2. The deposit suspected to contain uric acid or a urate may be 
dissolved in a drop of solution of potash, in which it is very soluble. 
Upon adding excess of acetic acid, and leaving the mixture for some 
hours, small crystals of uric acid will form. These may be recog- 
nised by their microscopical characters. 

3. Uric acid may be detected in animal fluids, when mere traces 
of this substance or of urates are present, by a plan proposed by my 
colleague (Dr. Garrod). The fluid suspected to contain the urate is 
treated with a few drops of strong acetic acid (glacial acetic acid is 
best) in a watch glass. A few filaments of tow or very thin silk are 
placed in the mixture, and the whole set aside under a glass shade 
in a warm place, for twenty-four or forty-eight hours. Gradually 
uric acid crystals separate, and are deposited upon the filaments. 
Their characters may be recognised by microscopical examination. 
Some crystals of uric acid upon a hair are represented in Plate XXI., 
Fig. 6, of the ^'Illustrations:' 

The quantity of uric acid is estimated by collecting the crystals 
separated by the addition of an acid, and weighing them after they 
have been carefully washed and dried. Dr. Thudichum recommends 
the use of nitric acid, because the uric acid is less soluble in it, and 
there is not so much tendency to the development of fungi as if 
hydrochloric be employed. 



FORMATION OF URIC ACID. 97 

188. Mode of Formation. — Uric acid is found in the urine of 
most carnivorous animals, and in that of young herbivora while 
sucking, and, therefore, feeding upon a diet rich in nitrogen. It 
is not found in the urine of the pachydermata, not even in that of 
the omnivorous pig. It is abundant in the urine of birds, and is 
found in that of many reptiles and insects. Uric acid exists in the 
blood, and is only separated from that fluid by the kidneys. Dr. 
Garrod has detected it in the blood of men in health, and in cases 
of gout in considerable quantity. In such instances, uric acid 
crystals may be separated from the fluid obtained from a blister, 
according to the plan just described. It has been detected in 
the juice of the spleen in considerable quantity by Scherer, but 
Mr. Gray has failed to confirm these observations. Cloetta has 
found it in the pulmonary tissue of bullocks' lungs, associated 
with taurine, inosite, and leucine. It has also been found in the 
brain and in the liver. 

Uric acid, like urea, is one of the products indirectly resulting 
from the disintegration of albuminous tissues. It is probable that 
it results directly from the action of oxygen upon substances formed 
by the red blood corpuscles. The formation of a large quantity of 
uric acid by birds is a fact strongly in favour of Liebig's doctrine, 
that uric acid is first produced, and that this is afterwards con- 
verted into urea. Prout held " that a very large proportion of the 
urate of ammonia found in the urine on common occasions appears 
to be developed from the imperfect albuminous matters formed 
during the assimilating processes.^' This is rendered probable by 
the researches of later observers, especially by those of Bidder and 
Schmidt. Uric acid may be deposited, in combination with soda 
and lime, in various structures. It may accumulate beneath the 
skin, so as to form large collections, which are familiar to us under 
the name of chalk-stones. It is curious that these depositions 
should take place in areolar tissue, in white fibrous tissue, and in 
connexion with cartilage. Perhaps this may be connected with the 
very slight vascularity of these tissues when fully formed, although 
they are highly vascular during the early period of their growth ; 
and it must be borne in mind that the deposits usually occur at a 
time of life when they are fully developed, after which they pro- 
bably undergo very slight changes, and the processes concerned in 
their decay and regeneration are slowly and, perhaps, in sedentary 



98 URATES. 

persons, very imperfectly carried on. These circumstances would 
favour the separation of a slightly soluble substance from the blood, 
and its deposition in an insoluble state. Lehmann has shown that, 
after attacks of disturbed digestion, the proportion of uric acid to 
the urea becomes increased. Alcoholic liquors seem to have the 
same effect. In normal conditions of the system, the urine contains 
about 1 part of uric acid to 28 or 30 parts of urea ; but, under the 
circumstances just mentioned, the ratio becomes 1 to 23 or 26. 
This increased proportion of uric acid appears to be formed in con- 
sequence of the usual proportion not being converted into urea. 
Alcohol causes a diminution in the quantity of carbonic acid 
exhaled ; and, in such cases, an increased proportion of uric acid, 
urates, and usually oxalates, is found in the urine. 

A highly nitrogenised diet, with insufficient exercise— confine- 
ment in ill-ventilated rooms — ^all circumstances interfering with the 
healthy action of the respiratory apparatus— or preventing the 
proper amount of blood being carried to the pulmonary surface, 
active exercise in confined air, &c., — are conditions favourable to 
the formation of an increased quantity of uric acid and urates. The 
formation of urea and oxalic acid from uric acid in the organism, or 
artificially by the action of peroxide of lead, has been previously 
alluded to. Kanke has shown that, at a high temperature, in the 
presence of yeast and an alkali, uric acid also becomes converted 
into urea and oxalic acid. 

180. Urates.— Uric acid is separated from the blood by the 
kidneys, in the form of a urate, which is readily soluble in water. 
After its separation, however, this salt may soon undergo decompo- 
sition, and insoluble uric acid will be deposited. In the majority of 
cases, this decomposition does not t-ake place until after the urine 
has left the bladder; but sometimes it occurs in the bladder itself. 
The causes of the precipitation of uric acid are well worthy of atten- 
tive study, as they are intimately connect-ed with the formation of 
uric acid calculi. The quantity of urates in healthy urine is very 
small, but not unfrequently enough is present to form a very abun- 
dant deposit after the urine has been allowed to stand for some time. 
I propose to describe the characters, and allude to the composition, 
of these salts, when the subject of urinary deposits is brought under 
notice. 



HIPPURIC ACID. 99 

140. Hlppxiric Acid (HOiCigH NOa) was first detected in horses' 
urine by Liebig, and was proved by him to exist in healthy human 
mine in small quantity — a statement which has been confirmed by 
Lehmann, and recently by Kiihne and Hallwachs. It is not found 
in the urine of carnivorous animals, but among herbivora it occurs 
in considerable quantity. It does not exist in large quantity in the 
urine of calves while sucking, but cows' urine contains as much as 
1*3 per cent. Lehmann has detected it in considerable quantity in 
the urine of the tortoise {testttdo grceca), 

Hippuric acid is soluble in about six hundred times its weight of 
cold water. It is very soluble in hot water, and also in alcohol, but 
is insoluble in ether. It crystallises very readily in various forms, 
which are derived from the right rhombic prism (Plate XI., Fig. 58 ; 
** Illustrations of Urine,^'* Plate IX., Fig. 1). It is very easily decom- 
posed into benzoic acid, especially in the presence of extractive 
matters, and other constituents of the urine. In testing for this 
substance, the perfectly fresh urine only should be employed. It is 
curious that benzoic acid, when taken into the organism, is eliminated 
in the urine in the form of hippuric acid — a fact which was first 
made known by Mr. Ure. 

It may be prepared by adding milk of lime to fresh cows' urine. 
The mixture is to be boiled for a few minutes, strained, and exactly 
neutralised with hydrochloric acid. The solution is next to be boiled 
down to one-eighth of its original bulk, and considerable excess of 
hydrochloric acid added, when brown crystals of the acid form. These 
may be purified by solution in water, through which a current of 
chlorine is to be transmitted, in order to decolorise the liquid. It 
may always be readily obtained from human urine after taking ten 
grains of benzoic acid. 

The quantity of hippuric acid is increased when a purely vege- 
table diet is taken; but it is certain that the whole of the hippuric 
acid formed in the organism is not derived from this source. The 
proportion of hippuric acid in human urine was formerly considered 
to be so small, that it was scarcely possible to make a satisfactory 
quantitative determination ; but Hallwachs has lately shown that as 
much as thirty grains or upwards are excreted in twenty-four hours. 
Weiflsmann obtained as much as 34*5 grains from his own urine in 
the course of twenty-four hours, when he was on a mixed diet. 

Very little is known with reference to the formation of hippuric 

F 3 



100 EXTRACTIVE MATTERS. 

acid; and although the subject has been very carefully investigated 
by Kiihne and Hallwachs, who have published two very elaborate 
memoirs, there still remains much to be discovered. These observers 
hold that the hippuric acid is produced from the glycocol formed in 
the liver. Hallwachs is led to conclude, from numerous experiments, 
that the production of hippuric acid is determined rather by the 
chemical changes going on in the organism, than by any peculiarities 
of the food; for, if a purely animal diet was taken, hippuric acid was 
still found in the urine.* Lehmann found much hippuric acid in 
the urine of fever patients, and always detected it in diabetic urine. 
Robin and Verdeil give drawings of some crystals which they 
found in the urine of a man aged 30, who took little exercise, but 
lived on highly nitrogenised diet : and which they considered to be 
hippuric acid: a statement apparently founded upon ^he resemblance 
of these crystals to those produced by the decomposition of hippurate 
of soda. They do not mention that the crystals were subjected to 
any chemical examination; and, in the absence of stronger evidence 
than mere resemblance in form, it seems to me that we are hardly 
justified in assuming that the crystals were composed of hippuric 
acid. It is very doubtftd if this acid ever crystallises in urine 
spontaneously. 

141. Extractive IJIatters.— Under the head of extractive matters 
are included certain organic substances which have never been 
obtained in a state of perfect purity, which are uncrystallisable — 
not volatile without decomposition — and incapable of being isolated. 
Chemists have described several kinds of extractive matters charac- 
terised by their behaviour with solutions of acetate of lead, bicloride 
of mercury, tincture of galls, &c. Within the last few years, however, 
several bodies, formerly included under the indefinite term of 
extractive matters, have been separated, and their chemical properties 
accurately determined. As instances, I need only mention albuminate 
of soda, binoxide and teroxide of protein, creatin and creatinine, 
hippuric acid, lactic acid and lactates, and certain colouring matters. 
The extractive matters in urine are entirely excrementitious; but it 
seems most probable that those present in the blood represent a 
certain stage of the metamorphosis of some of the constituents of 

• An excellent review of these researches will be found in VoL XIV., p. 166, of the 
" MecUco-Chirurgkal Review.** 



EXTRACTIVE MATTERS. 101 

that fluid — either a state intermediate hetween the nutritive 
pabulum and the tissue into which it is to be converted (progressive 
metamorphosis or histogenesis), or a condition resulting from the 
difidntegration of tissue previous to its elimination from the body in 
the form of urea, creatine, uric acid, <fec. (regressive metamorphosis 
or histolysis). The extractive matters of urine may be divided into 
three kinds. 

142. Water Extract.— The first is called water extract, because 
it is insoluble in absolute alcohol, and in spirit of specific gravity 
•833, but is soluble in water. It exists only in small quantity. 
Infusion of galls and bichloride of mercury produce scarcely any 
effect upon it, but neutral and basic acetates of lead give copious 
precipitates. 

143. Spirit Extract.— The second kind of extractive matter is 
termed spirit extract, because it is insoluble in absolute alcohol, but 
soluble in water, and in spirit '833. It contains much chloride of 
sodium. The solution of this extract is unaffected by infusion of 
galls, bichloride of mercury, and neutral acetate of lead; but a bulky 
precipitate is caused by basic acetate of lead. 

144. Alcoliol Extract.— The alcohol extract is soluble in water, 
in spirit '833, and also in absolute alcohol. Its chemical reaction 
appears to be very similar to the last. 

These are the extractive matters which are met with in healthy 
urine. In certain diseases, however, extractives drain off from the 
blood, and sometimes in very large quantity, which are not present 
in a state of health. My friend. Dr. G. 0. Rees, many years since 
showed that this extractive could be detected in morbid urine by 
adding tincture of galls ; and that the proportion varied greatly in 
different cases. Healthy urine is scarcely affected by tincture of 
galls, but this blood-extractive is at once precipitated by it. In 
order to detect it, tinctiii'e of galls is to be added to the filtered fluid; 
and if this extractive is present, a precipitate is at once produced. 
Should the urine contain albumen, this must, in the first instance, 
be separated by boiling and filtration. It is only the precipitate 
which immediately follows the addition of the tincture of galls that 
must be noticed. In some cases, the extractive drains away from the 
blood, without the escape of albumen. ("Lettsomian Lectures," by 



102 SULPHUR SUGAR. 

G. 0. Rees, M.D., F.R.S.; '^Medical Gazette;' 1851.) I shall have 
occasion to recur again to this interesting subject, when discussing 
the characters of the urine in disease. 

One thousand grains of healthy urine will contain from fifteen to 
twenty grains of extractive matters. The solid matter contains from 
15 to 40 per cent, of these substances. In twenty-four hours, about 
200 grains of extractive matters are eliminated in the urine. 

The physiological importance of extractive matters is quite 
unknown, and hitherto no one has been able to ascertain their 
nature, or discover the part which they play in the animal economy. 
Their presence in the blood, and in all the animal fluids, as well as 
in the solid organs and in the excretions, clearly prove them to be 
substances of great importance; and it must be remembered that, in 
the urine, the proportion of extractive matter is often greater than 
that of the urea itself. The amount of extractive matters in the 
different fluids and secretions of the body is a subject well worthy of 
investigation, and likely to yield valuable results. 

146. Sulphur Compounds.— In certain cases of disease, urine, 
soon after it is passed, evolves a very powerful odour of sulphuretted 
hydrogen, probably resulting from the decomposition of substances 
rich in sulphur. This fact has been observed by many, and I noticed 
frequently, in examining the urine of insane patients, a piece of 
paper, anointed with a solution of acetate of lead, soon became 
blackened from the formation of sulphuret. Considerable quantities 
of unoxidised sulphur have been obtained even from healthy urine. 
Ronalds, in five different cases, obtained from 3 to 5 grains of sulphur 
in the twenty-four hours (^^Philosophical Transactions;^ 1847), and 
Griffiths found 4 grains in healthy urine. These observations are 
confirmed by Dr. Parkes, and Bischoff and Voit have stated 
that a large quantity of sulphur is constantly present in the urine 
of dogs. 

146. Suerar. — Briicke has lately again stated that traces of sugar 
always exist in healthy urine, and his observations have been con- 
firmed by Dr. Bence Jones. {^^ Trans. Chem. Soc.;' April, 1861.) 
This subject will come under notice in a subsequent chapter. 

147. Vesical Mucus. — Vesical mucus exists in very small quan- 
tity in healthy urine. It forms a faint flocculent cloud, which settles 



LACnC AND OXALIC ACID. 103 

towards the lower part of the fluid, after the specimen has been 
allowed to stand for some time (§ 114). 

148. Iiactic Acid (2 HOiCigHioOio).— Lactic acid is not constantly 
present in healthy urine in quantities sufficient to be recognised; but 
sometimes it is found in the urine of persons who may be considered 
to be in tolerably good health. Liebig denied its existence in healthy 
urine altogether; but its presence in this fluid — at least, under certain 
physiological conditions, as stated many years ago by Berzelius — ^has 
been confirmed by Franz Simon, Lehmann, and others; although, on 
the other hand, it appears nearly certain that the salt assumed to be 
lactate of zinc by many observers was not really of this nature, but 
probably consisted of a combination of another acid, which, unlike 
lactic acid, contains nitrogen. 

In order to ascertain the presence of lactic acid, a baryta salt 
should be first prepared, as Lehmann has recommended, from which 
a lime salt is easily formed by the addition of sulphate of lime. The 
lactate of lime crystallises in double brushes, as seen by the micro- 
scope. From the lime salt a copper salt is prepared by the addition 
of sulphate of copper. (" The Microscope, in its Application to 
Clinical Medicine;' 2nd Edition, Figs. 123, 124, p. 123.) This is 
examined by the microscope. The lactate of coppe?: is decomposed 
by placing a small bar of zinc in the solution ; and upon this, in a 
short time, crystals of lactate of zinc are deposited, whose angles may 
be measured in the microscope. ("T^^ Microscope;^ <fec., 2nd Edi- 
tion, Fig. 125, p. 123.) For the details of this process, I must refer 
to Lehmann's ^^Physiological Chemistry;^ translated by Day, Vol. 
L,p.91. 

According to some observers, the phosphate of lime and the 
ammoniaco-magnesian phosphate are held in solution by the lactic 
acid. They may also be dissolved by the chloride of ammonium, 
according to Dr. G. 0. Rees. MM. Cass and Henry have endeavoured 
to prove that the lactic acid exists in the form of lactate of urea. 
Lactates of soda and ammonia are also most probably present in the 
majority of cases. Lactic acid is occasionally met with in urine, 
and some other organic acids which are sometimes present are 
described below. 

140. Oxalio Add (HOiGA) has been found in healthy urine 



104 SYSTEMATIC QUALITATIVE 

by Strahl and Lieberkuhn. B5cker estimated the quantity at 1-42 
grains in twenty-four hours. 

150. Peculiar Orfiranic Acids.— Besides carbonic acid, urine 
contains, according to the observations of Stadeler, a peculiar acid 
to which the name of damcduric acid has been given. It has a 
powerful odour; but little is yet known of the circumstances under 
which this volatile acid occurs. Phenylic or carbolic acid, usually 
known as creasote, has also been detected in urine ; but these acids, 
with the damolio and taurylic adds, as they occur in urine, have as 
yet been so little studied, that we know nothing of any practical 
importance connected with them. Campbell and Lehmann state 
that urine contains traces of formic acid (Cg H, 0*). 

Although the urea and some other constituents of the urine may 
be more conveniently and more quickly estimated, by the volumetric 
process of analysis (Chapter II.), the practitioner is recommended to 
carry out the following routine plan of analysis. In the course of 
the examination he will become practically familiar with the 
chemical and microscopical characters of the most important consti- 
tuents of the urine. Small quantities of the residues, &c., obtained, 
should always be submitted to microscopical examination. 

Ststematio Qualitative or Quantitative Analysis op 
Healthy Urine. 

161. Orgranic Constituents. — 1. In the first place, the reaction 
and specific gravity of the specimen are to be taken, and any general 
points noticed. (Lecture I.) 

2. Two portions of urine (500 or 1,000 grains) are to be placed 
in separate porcelain capsules, and evaporated to dryness with the 
cautions previously given. In the first portion, A, the organic con- 
stituents are to be estimated; in the second, B, the proportion of 
salts is to be ascertained (Chapter VII., § 183). A, when dry, is to 
be weighed; and thus the quantity of water is obtained. The residue 
is known to be quite dry when two successive weighings exactly 
correspond. The solid matter is to be treated with successive 
portions of boiling alcohol, until nothing more is taken up. These 
are decanted into another basin, or passed through a filter; and the 
alcoholic solution, containing urea and extractives, is to be evaporated 



AND QUANTITATIVE ANALYSIS. 105 

nearly to dryness — alcohol extract — C; the residue insoluble in 
alcohol — D. 

C. The alcohol extract is to be treated with a few drops of water, 
and placed over the water-bath. Crystals of oxalic acid are to be 
added until they are no longer dissolved. It is important to add 
excess of oxalic acid crystals. A drop of the solution may be placed 
on a glass slide, and the crystals of oxalate which form subjected to 
microscopical examination (§ 128, Plate XI., Fig 56). The mixture 
is allowed to cool, and the impure crystals of oxalate of urea and 
excess of oxalic acid are to be slightly washed with ice-cold water, and 
pressed between folds of bibulous paper, to absorb the extractive 
matters. The crystals are to be redissolved in a small quantity of 
water, placed in a large vessel, and carbonate of lime added until 
effervescence has entirely ceased. After the mixture has been 
allowed to stand for some time, it is to be thrown upon a filter. 

The solution separated from the oxalate of lime consists of urea 
with a little colouring matter. It is to be carefully evaporated to 
dryness, and weighed. If the residue is not entirely soluble in 
alcohol, it contains impurity which must be deducted from the 
weight of the urea. 

Or, the alcohol extract, C, may be treated with a few drops of 
water, so as to form a thick syrup; and nitric acid added by drops, 
while the basin which contains the extract is plunged in a freezing 
mixture. A little of the mixture should be examined in the 
microscope (Plate XI., Fig. 66), When sufficient nitric acid has 
been added to combine with all the urea present, the whole is to be 
allowed to stand for some time; the crystals carefully washed with a 
very little ice-cold water, and carefully placed on a porous tile, 
which will absorb the excess of nitric acid and the extractive 
matters, leaving crystals oi nitrate ofurea^ which are to be carefully 
dried and weighed. By a simple calculation, the quantity of urea is 
easily ascertained. 

D. The residue insoluble in alcohol is to be treated with boiling 
water and thrown upon a filter. There remain upon the filter, 
mucus from the bladder and other parts of the urinary mucous 
membrane; uric add; phosphate of lime; and ammoniaco-magnesian 
phosphate^ with a mere trace of sUica, This residue is to be care- 
fully dried and weighed. It is then to be incinerated ; and, after 
the ash has been completely decarbonised, its weight is to be 

r 5 



106 ANALYSIS OF URINE. 

deducted from that of the residue insoluble in alcohol ; and thus the 
proportion of uric acid and vesical mucus is ascertained. By deduct- 
ing the united weight of all these different substances — ^urea, uric 
acid, mucus, and earthy phosphate — ^from the solid matter, we 
calculate the quantity of extractive matter present. According to 
this plan, we have ascertained the proportion of the following 
constituents in 500 or 1,000 grains of urine. 

Water 

Solid Matter 

Urea 

Extractive matters 

Mucus and uric acid 

Earthy phosphate and silica 

Fixed salts . 

Many of the processes above described are imperfect, and likely 
to give results which are not quite accurate ; still the plan is one 
which is practically useful, and, when a series of results is required, 
answers very well. In the analysis of animal fluids, it is impossible 
to attain to perfect accuracy, owing to the changes taking place in 
the ingredients of the fluid, which are produced by the analytical 
processes to which they are subjected. Moreover, in such inquiries, 
it is far more desirable to know the general change which takes 
place, under various circumstances, in the quantities of the different 
constituents, than to be acquainted with the exact absolute pro- 
portion of each present. 



107 



CHAPTEE VII. 



Healthy Urine. III. Inorganic Constituents. — On the Salts 
generally — Changes effected in the Composition of the Salts 
by Incineration — Proportion of the Saline Matter in Urine 
— Phosphates — Common Phosphate of Soda — Alkaline 
Phosphate of Soda — Add Phosphate of Soda — Phosphate 
of Soda and Ammonia — Phosphate of Magnesia — Phos' 
phate of Ammonia and Magnesia — Phosphate of Lime — 
Estimation of the Alkaline and Earthy Phosphates — Qwaw- 
tity of Phosphates — Sulphates ; Quantity; Estimation — Car- 
bonates — Chloride of Sodium; Quantity; Detection — Cir- 
cumstances affecting the Excretion of Chloride of Sodium — 
Bases in Urine— Soda and Potash — Lime — Magnesia — Iron 
— Silica — Alumina — Systematic Quantitative and Qualitative 
Examination of the Saline Matter of Healthy Urine, 

Inoboanio Constituents op Healthy Ubine. 

The saline or inorganic constituents of healthy urine are composed 
of those substances which remain after the solid matter has been 
exposed to a red heat, and the carbon burnt off so as to leave a pure 
white ash. If a little of the solid matter of urine or other animal 
fluid be placed in a platinum capsule, or upon a piece of platinum 
foil, which should be very large in proportion to the quantity of 
solid matter operated on, and exposed to the red heat of a spirit or 
gas lamp, it will melt and boil up, giving rise to the evolution of 
offensive gases, which result from the decomposition of the organic 
constituents. When this has ceased, a charred mass, consisting of 
carbon and the saline matters indestructible at a red heat, of the 
urine, remains. After this black spongy mass has been kept in the 
open capsule, at a dull red heat, for a few hours, the carbon will 



108 INCINERATION. 

gradually disappear, in consequence of the action of the oxygen of 
the air, which at this temperature combines with it, and forms 
carbonic acid. A pure white ash, which has an alkaline reaction 
alone remains; and this consists entirely of saline or inorganic 
material, which is indestructible at a red heat. 

152. Ohan^res efTected in the Composition of the Salts by 
Incineration. — Now, it must not be concluded that the salts which 
we find in the ash existed in precisely the same state in the urine 
previous to incineration; for we know that many of these salts, 
when heated together, undergo mutual decomposition. Some of 
them may even be volatilised, if kept for a considerable time at a 
red heat. A mixture of carbonate of soda and chloride of ammo- 
nium becomes decomposed at a red heat. Chloride of sodium 
remains behind, while carbonate of ammonia is evolved. Any lac- 
tates, oxalates, and salts, of other organic acids present in the urine, 
will be found in the ash, in the form of carbonate, although no car- 
bonate existed in the urine originally. The ammoniaco-magnesian 
or triple phosphate will be found in the ash as phosphate of mag- 
nesia ; the phosphate of soda and ammonia, as phosphate of soda. 
Other phosphates also become completely changed by the process of 
incineration, and by the action of other salts present in the ash 
upon them. During the incineration, a considerable loss of chlorine 
also takes place. 

Again, unoxidised substances, such as sulphur and phosphorus, 
and partially oxidised compounds, in combination with organic 
materials, will become oxidised in the process of decarbonisation ; 
and will, therefore, be found in the ash in the form of sulphuric and 
phosphoric acid. These will react upon some of the bases present, 
and sulphates and phosphates will be formed. 

Professor Rose, of Berlin, in a beautiful series of experiments, 
has proved that the mineral constituents exist in very different 
states in various organic substances. From the carbonaceous ash of 
some organic matters, the greater proportion of the salts can be 
extracted with water or acids ; while, in other cases, but little saline 
matter can be separated, unless the mass be exposed to the oxidising 
action of the air for some time. This shows that the substances 
must have originally existed in an unoxidised or in a partially 
oxidised state, probably in combination with some organic material. 



FIXED SALTS. 1Q9 

In certain substances, then, the greater quantity of the mineral 
material is perfectly oxidised (teleoxidie) ; in others, it exists partly 
in an oxidised and partly in an unoxidised state (meroxidic). Pro- 
fessor Rose was not able to discover any substance in which it 
occurred completely unoxidised (anoxidic). In blood, milk, yolk of 
egg, and flesh, a considerable portion of the mineral constituents are 
meroxidic; while, in urine and bile, they are almost entirely teleox- 
idie: which is exactly what we should expect, when we consider the 
different nature and offices of these fluids. 

158. Proportion of Saline Matter in Urine.— About one- 
fourth of the solid matter of healthy urine consists of saline consti- 
tuents which are not destroyed by a red heat. 

One thousand grains of healthy urine, containing from forty to 
sixty grains of solid matter, will give from ten to fifteen grains of 
fixed salts. Of the salts, more than nine-tenths are soluble in water 
(alkaline salts) ; while the remainder can only be obtained in solu- 
tion by adding an acid (earthy salts). A mere trace remains behind, 
which is insoluble in water, acids, and alkalies. This consists of 
silica, with, perhaps, a little carbon which has resisted oxidation. 
These numbers are, of course, only approximative, as the amount of 
salts is liable to great variation. 

The saline constituents soluble in water are composed of the 
foUowing acids and bases : — 

Sulphuric acid (and sulphur). Potash (and potassium). 

Phosphoric Acid. Soda (and sodium). 

Hydrochloric acid (chlorine). 
The salts may be readily obtained in a crystalline state by 
dissolving the residue in hot water, and evaporating a few drops of 
the solution on a glass slide. The crystals are represented in the 
** Illustrations of Urine" Plate I., Fig. 2. 

The mineral constituents insoluble in water are composed of the 
following acids and bases: — 

Phosphoric acid. Lime. 

Carbonic acid (occasionally). Magnesia. 
Silicic acid or silica. Alumina (sometimes). 

In disease, the mineral constituents have been found to vary in 
quantity quite as much as the organic substances; and other salts 
are not unfrequently found, which will come under notice at a friture 



110 PHOSPHATES. 

time: while occasionally one or more of the saline compounds 
mentioned in the above list are altogether absent. 

The organic constituents of the urine have hitherto received a 
greater share of attention than has been given to the inorganic salts; 
but, from recent investigations, it seems probable that, before long, 
the physician will regard a departure from the healthy standard in 
the saline constituents, with as much attention as he has been 
accustomed to observe an increase or diminution in the quantity of 
the urea, uric acid, or other organic ingredients. 

154. Phosphates. — The phosphates are a very important class of 
salts, which exist in greater or less quantity in all the tissues of the 
body, in the secretions, and in considerable proportion in the blood. 
The salts of phosphoric acid which are carried off from the organism 
in the urine, may be divided into two classes. 

1. The alkaline phosphates are soluble in water, and are not 
precipitated from their solutions by ammonia or other alkalies. 
When ammonia is added to healthy urine, the alkaline phosphates 
are not thrown down. Some of the most important alkaline 
phosphates are phosphate of soda, add phosphate of soda, and 
phosphate of soda and ammonia. 

2. The earthy phosphates are insoluble in water, but are dissolved 
by the mineral acids. Most are soluble in organic acids, although 
they dissolve very slowly if the acids are dilute. They are held in 
solution even by carbonic acid. Most albuminous substances have 
the power of dissolving earthy phosphates; and casein holds in 
solution a considerable quantity of phosphate of lime. The earthy 
phosphates, as phosphate of lime and phosphate of magnesia, are 
always precipitated when ammonia is added to healthy urine. 

Of the phosphoric acid eliminated in the urine in the form of 
phosphates, the greater proportion is doubtless taken in the food; but 
a certain amount is formed in the organism by the oxidation of the 
phosphorus of albuminous tissues, which takes place during their 
disintegration. Much of the phosphoric acid formed in the organism 
is doubtless produced in the nervous tissue. 

Phosphoric acid is one of those acids which exist in three forms 
— ^the monobasic, bibasic, and tribasic acids, which combine respec- 
tively with one, two, or three equivalents of base, to form three 
different classes of salts. 



Tribasic phosphates 



ALKALINE PHOSPHATES. Ill 

;3NaO, P0» + 24Aq. 
2NaO, HO, P0* + 24Aq. 
' ' • ■^NaO,2HO,PO* + 2Aq. 

.Na 0, HO, NH* 0, P0'+8 Aq. 
Bibasic or pyrophosphates . 2 Na 0, PO* + 10 Aq. 
Monobajsic or metaphosphates Na 0, PO*. 

Now, the phosphates foimd in the organism are all tribasic 
phosphates, and consist of three equivalents of base, combined with 
one equivalent of phosphoric acid, with different proportions of water 
of crystallisation. The elements of the base of a tribasic phosphate 
may be various. Thus they may consist of three equivalents of soda 
or other base, or two equivalents of soda and one of water acting the 
part of a base, or one equivalent of soda and one of ammonia and one 
of water acting the part of a base, combined with one equivalent of 
phosphoric acid. 

The chemical composition of the phosphates occurring in urino 
is represented in the following table : — 

Common or rhombic phosphate ofJoT^. ^ xr^ PrV4.9i An 
soda, having an alkaline reaction. ( ^ ^a U, HO, PO» + 24 Aq. 

Add phosphate of soda, having an ^ ^^ ^^ ^ ^^, 

acid reaction .... J ' ' • i 

AlkaUne phosphate of soda, having a | 3 j^ q P0' + 24 Aq. 

highly alkaline reaction • • J ^ 

Phosphate of potash* . . . 3 KG, PC". 
Phosphate of ammonia and magnesia, ) 

ammoniaco-magnesian or triple > 2 Mg 0, NH*0, P0*+ 12 Aq. 

phosphate ) 

Acid phosphate of lime . . . 2 Ca 0, HO, PO" + 3 Aq. 
Phosphate of lime (bone-phosphate) 3 Ca 0, PO", 

Alkaline Phosphates. 

106. Ckxaunon Phosphate of Soda (2 Na 0, HO, F0'+24 Aq). 

— ^This salt exists in healthy urine in the proportion of about two 
grains in one thousand. The fixed salts contain perhaps from 20 to 
30 per cent, of ordinary phosphate of soda. Its presence in healthy 
urine may be proved by adding absolute alcohol to the syrupy fluid 

* It is donbtfal if phosphate of potash usually exists in urine, as chloride of sodium 
and phospliate of potash decompose each other, forming chloride of potassium and 
phosphate of soda. It is not improbable that it may exist in urine in which the chloride 
of sodium is present in very small quantity, or altogether absent, as in pneumonia and 
some other acute diseases. 



112 PHOSPHATE OP SODA. 

obtained by evaporating the urine over a water bath. This concen- 
trated fluid is poured off from the salts which have crystallised, and 
placed in a small glass vessel. The alcohol is added; and, after the 
mixture has stood for some time, the crystals are deposited upon the 
sides of the glass. This method is given by Robin and Verdeil. 
(" Traite de Ghimie Anat, et Physiol,,^ par Ch. Robin et F. Verdeil.) 

156. Acid Phosphate of Soda (Ka 0, 2 HO, F0' + 12 Ao).— This 

salt has only been found in the urine; and to it, at least in many 
cases, the acid reaction of the urine is due. This acid phosphate of 
soda may be formed from the common phosphate (which has an 
alkaline reaction), by the addition of uric acid, which removes from 
the common phosphate one equivalent of soda, forming urate of soda ; 
and the reaction of the mixture becomes acid, in consequence of the 
formation of the acid phosphate. 

The acid phosphate of soda may be obtained from the concentrated 
urine treated with absolute alcohol, after the separation of the 
common phosphate. The acid salt, which is much more soluble, 
becomes deposited in the course of a few days; but its separation 
may be expedited by the addition of ether. The phosphate has been 
separated from the urine by MM. Robin and Verdeil, who attribute 
the acid reaction of urine to its presence i^^Gomptes Rendus. Mhn.de 
la 8oc. de Biologie,''^ Paris, 1850, p. 25; also "TraitS de Ghimie Anat, 
et Physiolf' 1853). The crystals of this salt are figured in Robin 
and Verdeil's ''Atlas;' Plate IX., Fig. 2. 

157. Alkaline or Basic Phosphate of Soda.— 3 Ka 0, FO' + 24 Aq. 

— ^This phosphate is considered by some to be present in urine ; but 
it is so readily altered by other salts present, that it is impossible to 
obtain it from the animal fluids in a state of purity. In the presence 
of carbonic acid, it is decomposed: one equivalent of soda unites with 
the carbonic acid to form carbonate of soda, and common phosphate 
of soda is formed, both which salts have an alkaline reaction — 3 JSTa, 
0, P0* + C0»+H0=2 Na 0, HO, PO» + Na 0, CO*. 

Liebig has shown that it is not present in healthy urine, as was 
stated by Heller ; and Messrs. Robin and Verdeil do not enumerate 
this phosphate as one of the constituents of urine : indeed, if this 
phosphate were formed, it would, in all probability, be at once 
resolved into salts of a more stable nature. ■■ • - ■ 



QUANTITY OF PHOSPHATES. 113 

158. Phosphate of Soda and Ammonia (Na 0, NH'O, HO, FOs 

+8 Aq.) — TMs salt, although probably not present in perfectly fresh 
urine, is usually enumerated as one of the phosphates found in the 
secretion. The crystals of phosphate of soda and ammonia, or 
microcosmic salt, are beautiful transparent four-sided prisms. 

169. Phosphate of Potash (3 KO, PO") is probably not present 
in healthy human urine ; but it has been detected by Bossingault in 
the urine of the pig, in the proportion of 1*02 per 1,000. 

Many vegetable tissues contain a large quantity of phosphate of 
potash ; and it is met with in the juice of muscle in considerable 
quantity. 

160. Quantity. — The proportion of alkaline phosphates in the 
organism varies very greatly according to the nature of the food, 
amount of exercise, &c. Generally, the proportion is smaller in 
herbivorous than in carnivorous animals. Muscular fibre contains a 
large amount of phosphates. Wheat, and the seeds of the cerealia 
generally, contain a considerable quantity of alkaline phosphates. 
Robin and Verdeil found, in the ash of the blood of a dog fed upon 
flesh, as much as 12 per cent, of phosphoric acid, combined with 
soda and potash ; while the ash of the blood of the ox did not con- 
tain more than 3 per cent. When the dog was fed upon potatoes, 
the proportion fell to 9 per cent. The ash of the blood of man con- 
tained about 10 per cent, of phosphoric acid. In urine, Berzelius 
found 2*94 per 1,000 ; and Simon, from 1*25 in slightly acid urine, 
to 275 in very acid urine. 

Breed and Winter estimate the quantity of phosphoric acid 
removed from the organism in the urine, in the course of twenty- 
four hours, at from 59*48 to 79*97 grains. The proportion increased 
considerably after taking food. This quantity corresponds to from 
120 to 160 grains of phosphatic salts. Dr. Parkes estimates the 
phosphoric acid at 48*80 grains in 24 hours. 

The quantity of phosphoric acid increases for some hours after a 
meal. Vogel, Winter, and others have made numerous experiments 
on this point ; and their researches show that the hourly variation 
in the excretion of phosphate is regular. The morning urine con- 
tains the smallest quantity. In some of Dr. Bence Jones's analyses, 
however, the quantity of alkaline phosphates is even greater in the 
urine passed before than in that secreted after a meal. (^'Animal 
Chemistry," p. 81.) 



114 QUANTITY OF PHOSPHATES. 

The proportion of phosphates in the urine depends much upon 
the nature of the food. The quantity is increased if phosphorus be 
taken, proving that this substance does become oxidised in the 
organism. That the greater proportion of the alkaline phosphates 
present in the urine are derived from the food is rendered evident 
by referring to the amount introduced into the organism in this 
manner. A man taking about fourteen ounces of bread and twelve 
ounces of meat, with half a pound of potatoes and half a pint of 
milk, would take about 130 grains of alkaline phosphates.* As we 
have seen, he would eliminate, in his urine, about the same quantity. 
These numbers are only to be regarded as rough approximations to 
the truth ; but I think, at present, it must be admitted that the 
quantity of phosphate excreted in the urine, and formed in the 
organism, is so small in comparison to that derived from the food, of 
which the amount is liable to great variation, that, in the present 
state of animal chemistry, it is quite impossible to form an estimate 
of the amount derived from the former source, or to separate this 
from the phosphates taken in the ingesta. 

Still it is certain that some of the phosphoric acid is formed 
within the organism, by the oxidation of the phosphorus of the 
albuminous tissues; but this must bear but a small proportion to 
the whole amount of phosphate removed in the urine, as the above 
data conclusively show. 

The fluid which surrounds the elementary fibres of muscle has an 
acid reaction, depending probably upon the presence of acid phos- 
phate of soda, produced by the action of lactic or some other organic 
acid upon phosphate of soda. Du Bois Raymond has, however, shown 
that this acid reaction is not met with when the muscles are at rest. 
Recent experiments have shown that the amount of disintegration 
taking place in muscular tissue during its activity is much less than 
was supposed. It is probable that very much of the material gene- 
rally ascribed to the disintegration of the muscle is really due to the 
chemical changes produced in the nerves ramifying on the surface of 
the elementary fibres. The ashes of most tissues contain phosphates 

* 14 ox. of bread contain 53*2 grs. of phosphates. 
12 oz. of beef „ 407 „ „ 

4 lb. of potatoes „ 11*0 „ ,» 

i pint of milk „ 32-0 „ „ 

136-9 grs. of mixed phosphates. 



EABTHT PHOSPHATES. 115 

in large proportion; and Schmidt has shown that a consideiahle 
quantity of phosphate is always present in young tissues. The 
quantity of alkaline phosphate required by the organism is con- 
siderable; for, besides the large proportion which is excreted in the 
urine, the ash of the solid excrements contains as much as 20 per 
cent, alone. The phosphoric acid required is, no doubt, supplied 
principally by the food, partly in the form of phosphatic salts, partly 
as phosphorus which is oxidised in the organism. We shall recur to 
this subject when we have to consider the elimination of the phos- 
phates in disease. 

Earthy Phosphates. 

The earthy phosphates met with in the urine are — 1, the amma- 
fdaeo-magnesian phosphate^ also termed triple phosphate, or phos- 
phate of ammonia and magnesia; 2, Basic phosphate of ammonia 
and magnesia; 3, Phosphate of Magnesia, 

These earthy phosphates occur in very small quantity in urine. 
The secretion in health contains not more than from 1 to 1*5 part 
in 1,000, and the solid matter contains from 1*5 to 2 per cent. The 
quantity present in different cases undergoes but slight variation, 
and seems to be determined, to a great extent, independently of the 
chemical changes going on in the body. Most of the solids and fluids 
of the organism contain small quantities of the earthy phosphates. 
The amount depends, in great measure, upon the quantity of alkaline 
earths present. Ktetzinsky has shown that in urine there are two 
parts of phosphate of lime to one part of phosphate of magnesia. 

In healthy urine, these earthy phosphates are held in solution, 
in all probability, by the free acid of the urine, and in some measure 
by the acid phosphate of soda. The chloride of ammonium present 
may also contribute to maintain the earthy phosphates in solution 
in the urine (Dr. G. 0. Rees). Very slight changes are sufficient 
to cause the precipitation of the ammoniaco-magnesian phosphate ; 
and beautiful crystals of this salt are sometimes formed in urine 
which has a decidedly acid reaction. 

It is important to distinguish between excess of phosphates in 
the urine and a deposit of earthy phosphate ; for a large quantity of 
earthy phosphate in the urine may pass unnoticed by the prac- 
titioner, because it is in a state of solution; while a smaller quantity 
in an insolvhle state, and therefore very conspicuous, is likely to 



116 PHOSPHATE OF UME. 

receive from him a larger share of attention than its slight import- 
ance demands. 

161. Precipitation of Earthy Phosphates by Heat. — It is very 
important to bear in mind that the earthy phosphates are precipi- 
tated from some specimens of urine by heat. This precipitate 
closely resembles that which is produced, in many specimens of 
albuminous urine, upon the application of heat. It is, however, at 
once distinguished from albumen by the addition of a few drops of 
nitric acid, which instantly dissolves the phosphate, while albumen 
is unaffected by it. Such a mistake has many times been made ; 
and I need hardly say how important it is to avoid the possibility of 
such an error, as it may lead the practitioner to form an unfavour- 
able prognosis in a case in which there is really no cause whatever 
for anxiety. The cause of this occasional precipitation of earthy 
phosphate is obscure. By Dr. Rees it is attributed to an excess of 
the phosphates being held in solution by chloride of ammonium. 
Dr. Brett considers that in these cases it is dissolved by carbonic 
acid; while Dr. Bence Jones attributes this precipitation to the 
excess of free acid of the urine being neutralised by an alkali, or by 
common phosphate of soda. 

162. Phosphate of Lime (3 Ca 0, PO") exists in healthy urine 
dissolved in acids, in certain salts, or in organic matters. Phosphate 
of lime is soluble in a solution of carbonic acid, in bicarbonates, and 
in chloride of ammonium. Albumen and fibrine always retain a 
certain quantity, and casein holds a large amount in solution. It is 
found in almost all the tissues, and, when separated, usually occurs 
in an amorphous state. In urine it sometimes crystallises. The ash 
of urine contains between 2 and 3 per cent, of this phosphate, and 
that of excrements upwards of 12 per cent. It may be obtained 
in quantity from bones. 

163. Acid Phosphate of Lime (2 Ga 0, HO, P0'+3 HO.— The 
existence of this phosphate in urine constantly, is questionable; but, 
as before remarked, the composition of the phosphates is constantly 
altering ; and an acid phosphate of lime is readily formed by the 
action of an organic acid on the neutral phosphate of lime. 

164. Phosphate of Ammonia and Magmesia, Triple, or 



PHOSPHATE OF MAGNESIA. 117 

Ammoniaoo-Magmesiaii, Phosphate (KH* 0, 2 Mg 0, F(H + 12 HO) 

The presence of this salt, which is frequently met with in the animal 
fluids, usually depends upon decomposition having commenced, in 
which case the ammonia set free combines with the phosphate of 
magnesia to form the triple phosphate. At the same time there can 
be no doubt that crystals of triple phosphate are sometimes found in 
acid urine — not merely forming a pellicle which alone is alkaline, 
while the fluid beneath retains its acidity (Thudichum) — ^but as a 
distinct deposit, leaving a clear supernatant fluid. Lehmann and 
other observers doubt the correctness of this observation; but the fact 
has been observed in this country several times, and I have noticed 
it myself more than once or twice. It is quite possible that the acid 
reaction may depend upon chloride of ammonium, or some other 
salt which reddens litmus, and not upon the existence of free acid. 

Crystals of triple phosphate are slightly soluble in pure water, 
but are rendered quite insoluble by a trace of ammonia and ammo- 
niacal salts. They give beautiful colours when examined with a ray 
of polarised light. 

165. Phosphate of KCasniesia (3 Mg 0, P0» + 7 Aq.) — This 
phosphate is found in considerable quantity in the urine of certain 
herbivorous animals, and it appears to be a constituent of certain 
urinary calculi. It is doubtful if it is often present in human urine; 
but Robin and Verdeil have discovered it in several organs, and also 
in morbid products. In animal fluids generally, the phosphate of 
magnesia combines with ammonia, forming the salt which has just 
been described. When discussing the deposits of phosphates, I shall 
have to revert to this subject. 

166. ICicrosoopical Characters of the Earthy Phosphates. — 

The phosphate of lime is usually deposited from urine in an amor- 
phous form. Under the microscope, even when the highest powers 
are employed, the deposit when first formed is found to consist of 
minute granules. {^^ Illustrations,'^ Plate XXL, Fig. 4.) Occa- 
sionally it occurs as round or oval particles of a high refractive 
power. Sometimes two of these small particles are connected 
together, and produce a crystal of the dumb-bell form. They vary 
much in size, but are usually very small. 

After some time has elapsed, the amorphous granular deposit of 
phosphate of lime assumes a crystalline form. Dr. Hassall has found 



118 ESTIMATION OF PHOSPHATES. 

that the crystals formerly regarded as a rare form of triple phosphate 
are really composed of phosphate of lime. Dr. Bence Jones has also 
obtained crystals of phosphate of lime from urine by adding chloride 
of calcium, and Dr. Roberts has written a paper on the same subject. 
I have found that beautiful crystals of phosphate of lime can always 
be obtained by allowing solutions of phosphate of soda and chloride 
of calcium in glycerine gradually to mix together. In this manner 
very perfect crystals may be produced. Many days may elapse before 
large crystals are found. 

The phosphates of magnesia crystallise in several different forms, 
which seem to be determined by slight changes in circumstances. 
The first is the stellate form, which occurs when ammonia is added 
to healthy human urine. The crystal consists of from four to five 
feathery rays, with a minute oval mass situated at the origin of each 
ray from the centre. These crystals gradually assume the more 
common form of the triple phosphate: secondly, that of a beautiful 
triangular prism, with obliquely truncated extremities. Great 
variation, however, is observed in the form of these crystals; some- 
times they appear almost square; and frequently they might be 
mistaken for octohedra, in consequence of the approximation of the 
obliquely truncated ends, and the shortening of the intermediate 
portion of the crystal. Prisms or knife-rest crystals of triple 
phosphate are represented in Plate XII., Fig. 62. The feathery 
crystals of triple phosphate are represented in the " Illustrations,''^ 
Plate IX., Fig. 2. After standing for' some time, the rays alter in 
shape, and gradually little triangular crystals begin to make their 
appearance, as represented at a. After the lapse of some days, they 
are entirely converted into the ordinary triangular crystals. (" Illus- 
trations;' Plate IX., Fig. 1.; Plate XXI., Figs. 1, 3; Plate XXIII., 
Fig. 1). Other forms of triple phosphate are described in the 
chapter on urinary deposits, 

167. Estimation of the Earthy and Alkaline Phosphates. — 
The earthy phosphates (phosphate of lime and phosphate of mag- 
nesia) are easily detected by ammonia. If a few drops of solution of 
ammonia are added to a specimen of healthy urine, a turbidity is 
soon observed, owing to the precipitation of phosphate of lime in an 
amorphous form, and triple or ammoniaco-magnesian phosphate in 
flocculent snow-like crystals, which increase in size for some time 



SULPHATES. 119 

after their first precipitation. Stirring favours the separation of the 
phosphates ; hut the form of the crystals must, of course, he studied 
in a mixture which has heen allowed to remain quiet. If it is 
required to estimate the proportion of these earthy phosphates, it is 
only necessary to separate them hy filtration, ignite in a platinum 
capsule, and weigh the ash. 

168. Alkaline Phosphates.— The phosphoric acid comhined with 
the alkalies may he precipitated from the fluid filtered from the earthy 
phosphates hy the addition of a salt of lime or magnesia, when an 
insoluhle deposit, composed of phosphate of lime or phosphate of 
ammonia and magnesia, is produced. If it is desired to ascertain 
the quantity of alkaline phosphates, it is only necessary to filter the 
precipitate, dry, ignite, and weigh it. From the phosphate of lime 
or phosphate of magnesia it is easy to calculate the proportion of 
phosphoric acid present ; hut, for ordinary purposes, it is enough to 
consider the weight as corresponding to the quantity of alkaline 
phosphates present in the urine, there heing hut slight difference in 
the equivalent numhers of the salts. The volumetric method of 
estimation, in which the phosphate is precipitated hy a persalt of 
iron, has heen described in Chapter II. Nitrate of silver pro- 
duces in urine a yellow precipitate of trihasic phosphate of silver, 
which is soluble both in excess of ammonia and also in nitric acid. 
Upon adding a few drops of the former to the yellow deposit in this 
test-tube, it instantly dissolves. If nitric acid just sufiicient to 
neutralise the ammonia present be added, the yellow precipitate re- 
appears; but, when one drop more falls in, it is immediately redis- 
solved. This might be repeated many times. The precipitate of 
chloride of silver is quite insoluble in nitric acid, although soluble 
in ammonia ; so that, in testing for chloride of sodium in urine, it is 
always important to add a few drops of nitric acid, to prevent the 
precipitation of the phosphate of silver. 

160. Sulphates. — ^Unlike the phosphates, the sulphates are pre- 
sent in very small quantities in the fluids of the body generally. 
The urine, however, contains a large quantity. This class of salts is 
not present in the milk, bile, or gastric juice. The blood contains 
only '20 per 1,000; while, in healthy urine, sulphates exist in the 
proportion of from 3 to 7 parts per 1,000. 

The proportion of sulphates undergoes a considerable increase 



120 SULPHATES. 

after violent exercise, and under the influence of a purely animal 
diet — conditions under which the urea suffers a considerable aug- 
mentation. In fact, in all those conditions which are associated 
with an increased formation of urea, a large proportion of sulphates 
will also be observed. It would appear that the oxygen, hydrogen, 
carbon, and nitrpgen of the albuminous substances, are eliminated 
in the form of urea; while the sulphur is removed in the state of 
sulphuric acid. 

Dr. Bence Joneses experiments have shown that both vegetable 
and animal food increase the proportion of sulphates in the urine. 
When sulphuric acid, sulphur, or sulphates, are taken internally, 
the amount of these salts is augmented. These facts prove that the 
sulphates found in the urine are in great part formed during the 
disintegration of tissues. They must be regarded as excrementitious, 
and are probably not concerned in nutrition. 

The sulphuric acid eliminated in the urine occurs in the form of 
sulphate of potash and soda. 

The urine contains about 3*5 grains per 1,000 of sulphate of 
potash, and about 3*0 grains of sulphate of soda. About thirty 
grains of sulphuric acid, corresponding to about fifty-seven grains of 
the mixed sulphates, are excreted by a healthy man in twenty-four 
hours. 

The sulphates present in the urine are all soluble, like the alka- 
line phosphates ; and, in order to prove their presence in a fluid, it 
is necessary to add some salt, the base of which forms an insoluble 
precipitate with sulphuric acid. Baryta salts are the most conve- 
nient for this purpose. Either the nitrate of baryta or the chloride 
of barium may be employed. In testing for sulphates in urine, it is 
necessary to add a little free nitric or hydrochloric acid previous to 
the addition of the baryta salt, in order to prevent the precipitation 
of a phosphate as well as a sulphate of baryta. The former is very 
soluble in free acid; the latter quite insoluble. If the quantity 
of sulphate is to be estimated, it is necessary to boil the mixture, or 
to drop the baryta salt into the boiling solution ; otherwise the pre- 
precipitated sulphate of baryta will pass through the pores of the 
filter. The phosphoric acid may be estimated in the clear fluid 
which passes through the filter by the addition of ammonia, which 
throws down phosphate of baryta. The contact of the air must, in 
this case, be avoided. 



FIXED SALTS. 121 

170. Sulpliate of Lime has not been detected in human urine, 
but it has been found in that of animals, and is a constituent of 
some urinary calculL I have seen crystals of sulphate of lime in 
the uriniferous tubes ; and it is probable that it may be present in 
the urine, in some cases, in appreciable quantity. Traces of sul- 
phate of lime are found in the blood. It is found in the pancreatic 
juice which has been kept for a few hours in a warm place, so that 
decomposition of some of the organic materials may take place. 

171. Carbonates.— Carbonate of soda is not usually reckoned as 
a constituent of healthy urine, as its presence is entirely dependent 
upon the kind of food which the person has taken. For instance, 
carbonate of soda will often be found in the urine after large 
quantities of fruit have been eaten, in consequence of the salts of the 
vegetable acids becoming converted into carbonates during their 
passage through the organism. In the urine of herbivorous animals, 
alkaline carbonates are found; and frequently the carbonate of lime 
is also present. In the urine of rodents, these salts, particularly the 
latter, are abundant. Moreover, carbonate of soda may actually have 
been present in the urine, although it cannot be detected in the ash; 
for, if common phosphate of soda be heated with carbonate of soda, 
the carbonic acid is expelled, and the tribasic phosphate of soda 
remains. Hence the absence of carbonate from the ash of urine is 
not always a positive proof that the fluid did not contain lactates 
before it was subjected to chemical operations. On the other hand, 
a carbonate may be detected in the ash, although none was present 
in the urine, in consequence of the decomposition of oxalates and 
lactates during incineration. 

172. Testingr for Carbonate. — The presence of carbonic acid is 
very easily recognised, by the effervescence set up, immediately a 
little dilute acid is added to the ash. The best plan to test for 
carbonate in the ash is the following. A small portion of the dry ash 
is placed on a glass slide, and covered lightly with an ordinary square 
of thin glass. A drop of acid is then allowed to fall on the glass, so 
that it will gradually pass between the glasses by capillary attraction, 
and come into contact with the salt. If any bubbles of gas escape in 
consequence of the action of the acid, they will be confined beneath 
the thin glass, and one cannot fail to see them. If they be very 



122 CHLORIDE OF SODIUM. 

small, the specimens may be subjected to microscopical examination. 
In this manner, the slightest trace of carbonic acid can hardly escape 
notice. 

If the quantity of carbonate is to be estimated, the ash must be 
placed in a little apparatus, from which the gas is conducted by a 
tube into another vessel containing lime or baryta water; or it may 
be caused to pass through the potash apparatus used in organic 
analysis. From the weight of the carbonate, that of the carbonic 
acid is easily calculated. In the last case, its weight is obtained 
directly. 

173. ChlorldeofSodiam(KaCl).— Common salt is always present 
in healthy urine, although the proportion is liable to great variation, 
owing to the circumstance that the chloride of sodium is always 
derived from the food. The importance of this substance to the 
organism is sufficiently proved by the fact that all kinds of food 
contain a certain quantity, and almost every specimen of water holds 
some proportion in solution. Again, it is well known that the health 
of animals deprived of the proper amount of salt, deteriorates. It is 
to be detected in nearly all the tissues of the animal body, and is 
found in large quantity wherever cell-development is actively going 
on. This is true both with regard to healthy tissues and morbid 
growths. Common salt crystallises in cubes; but, in the presence of 
urea and some other organic substances, it assumes the form of a 
regular octohedron. As is well known, it is readily soluble in water 
(31*84 parts in 100), diffuses itself rapidly through a large bulk of 
fluid, and, in a dilute state, permeates tissues with great facility. 

Besides common salt, urine also contains a certain quantity of 
chloride of potassium. 

174. Quantity.— Healthy urine contains from three to eight 
grains of chloride of sodium in 1,000 ; the solid matter, about 6 per 
cent.; and the fixed salts, about 25 per cent, or more. Under 
ordinary circumstances, from 100 to 300 grains of salt are removed 
from the body in twenty-four hours; but the proportion is influenced 
by a great variety of circumstances, and is especially effected by the 
quantity of fluids taken. Dr. Farkes estimates the quantity of 
chlorine at from 92 to 124 grains in twenty-four hours. The amount 
is very variable in different individuals, according to the proportion 



THE EXCRETION OF SALT. 123 

of salt taken with the food. The secretion of chloride of sodium, as 
would be supposed, attains its maximum a few hours after a meal, 
and but little is eliminated during the night. 

176. Detection.— Chloride of sodium is very easily detected in 
urine. It is only necessary to acidulate the specimen with a few 
drops of nitric acid, and then add nitrate of silver. The white 
precipitate of chloride of silver is quite insoluble in nitric acid, but 
soluble in ammonia. In order to make a quantitative determination, 
the chloride of silver is to be dried; and it should be burnt and 
fused in a porcelain capsule before being weighed. The volumetric 
process, however, is the most accurate (§ 40). 

176. Oirctunstanoes aifeotingr the Excretion of Salt. — Chloride 
of sodium is not formed in the organism, but seems to exert some 
important and beneficial efiects during its passage through the 
tissues; and whenever the nutritive changes are very active, there 
seems to be an unusual demand for chloride of sodium. But the 
precise part which the substance plays is at present unknown. The 
quantity of salt excreted in the urine undergoes great changes in 
certain diseases. The proportion also varies considerably from day 
to day, under the influence of an ordinary diet in health; and the 
ingestion of large quantities of water causes the elimination of a 
greatly increased amount of common salt. Thus, in one experiment, 
continued for four days, the following results were obtained : during 
the first three days, about thirty-six ounces of urine were passed per 
diem; the specific gravity varied from 1,016 to 1,024. The total 
quantity of solid matter passed in twenty-four hours was about 750 
grains, and the chloride of sodium amounted to 113 grains. On the 
fourth day a large quantity of water was taken; 258^ ounces of urine, 
of specific gravity 1,003, were passed; containing a total of 1134*48 
grains of solids, and 232-8 grains of chloride of sodium. The phos- 
phoric acid was diminished, and the sulphuric acid was increased by 
upwards of one-third. 

177. Soda and Potash (KaO & EO).— In healthy urine but a very 
small quantity of potassium is present in the form of chloride; but of 
soda salts there is a large proportion. The potash salts, as was first 
pointed out by Liebig, are found in considerable quantities in the 
muscles, while the soda salts predominate in the blood. Although 

a 3 



124 LIME — ^BfiAONESIA. 

phosphate of potash he taken in the food, the corresponding soda 
salt, which is necessary to the hlood, is still found in that fluid; and 
there can be no doubt that, in the organism, the chloride of sodium 
is decomposed by the phosphate of potash — a phosphate of soda and 
a chloride of potassium being formed. 

To separate the sodium from the potassium in urine, a somewhat 
tedious analysis, of which I will just give a rough outline, is 
necessary. After destroying the organic matter by ignition, the 
whole of the phosphoric and sulphuric acids are removed, and the 
potassium and sodium converted into chlorides. A solution of 
bichloride of platinum is then added, and a chloride of potassium 
and platinum, and a chloride of sodium and platinum are formed. 
The potassium salt is most insoluble, and separates in the form of 
small octohedra, which do not polarize light. These may be sepa- 
rated by filtration. The sodium salt remains in solution, and may 
be obtained in the form of crystalline needles by concentrating the 
solution. These crystals exhibit the most beautiful colours when a 
ray of polarized light is transmitted through them. 

178. Lime (CaO) may be detected in urine by dissolving the salts 
in acetic acid, and adding a little oxalate of ammonia to the filtered 
solution. Oxalate of lime is precipitated as a white, granular 
powder, which passes through the pores of a filter, unless the 
mixture be boiled previous to filtration. As already mentioned, 
lime occurs in urine as a phosphate, and occasionally as a car- 
bonate. It forms a urinary calculus very rarely met with in man ; 
but not uncommon in some herbivorous animals. The urine of the 
horse always contains a number of spherical masses, composed of 
carbonate of lime, which may be regarded as microscopic calculi. It 
has been proved by Mr. Rainey that the spherical form which 
crystalline matter sometimes assumes, depends upon the presence of 
viscid matter in the solution which contains the crystalline matter. 
These spherical crystals of carbonate of lime, so constantly found in 
horse's urine, may be exactly imitated by causing carbonate of lime 
to crystalize artificially from gum water or other viscid fluids. i^^The 
mode of formation of shells ^^ <fec.) 

170. Magrnesia (MgO) must be precipitated as Ammoniaco-mag- 
nesian phosphate, from a concentrated solution of the salts after the 



IRON SILICA — ^ALUMINA. 125 

separation of the lime. The fluid should be evaporated to a small 
bnlk, and when quite cold a little of the solution of phosphate of 
soda should be added to the mixture, rendered alkaline by the 
previous addition of ammonia. Unless there be already a sufficient 
quantity of ammoniacal salt in the mixture, some muriate of 
ammonia should be added, as the magnesian salt is slightly soluble 
in pure water, but insoluble in solutions of ammoniacal salts. 

The solution should be stirred in all cases, for by this means a 
precipitate can often be produced, although before not the slightest 
turbidity was observable. 

180. Iron (Te).— Traces of iron may be detected in healthy urine 
if a large quantity of the secretion be operated upon. Like many other 
mineral substances, iron passes oflf in small quantities in the urine, 
and is generally found in the urine of persons taking preparations 
of iron. Dr. Harley has shown that iron is a constituent of one of 
the colouring matters of the urine. ( UrcBmatine,) 

181. Silica (SiOg).— Berzelius, many years ago, demonstrated the 
presence of sUieic acid, or silica, in urine. Mere traces are met 
with in the ash after the removal of the salts insoluble in water, by 
the addition of strong nitric acid. The silica remains undissolved. 
This substance is derived principally from wheat, which, like other 
plants belonging to the cerealia, contains a considerable proportion 
of silica. Silica has been occasionally met with in urinary calculi, 
in appreciable quantity. 

182. Alumina (AI3O3).— It has been stated by authorities that this 
substance does not pass off from the system in the urine at all ; but 
from several observations which I made some years since, and which I 
have lately repeated, I have been led to conclude that it is very 
commonly present in the ash of urine. The alumina detected in the 
urine is in great part, if not entirely, derived from the alum taken 
in the bread. Some time since, while in the habit of eating pure 
home-made bread, I was unable to detect the presence of this sub- 
stance in the manner presently to be described; but afterwards, 
when my diet consisted of baker's bread, I found very decided 
indications of its presence. 

The test which has been employed is the ordinary blow-pipe test. 
A little of the fixed saline residue, which has been perfectly decar- 



126 SYSTEMATIC QUALITATIVE 

bonised, is moistened with a solution of nitrate of cobalt, and heated 
gradually in the blow-pipe flame to a bright red heat. If alumina 
be present, the bead, upon cooling, is found to be of a beautiful 
bright blue colour. As is well known, there is great difficulty in 
separating phosphate of alumina from phosphate of lime; and the 
ordinary process of analysis is not sufficiently delicate to detect this 
substance in the small quantity in which it ordinarily occurs in the 
ash of urine. When the ash contains as much as one-fiftieth part, 
however, I have been able to detect it by the liquid tests. The 
blow-pipe test above referred to is not without objection, inasmuch 
as any bead containing phosphates exhibits a blue colour when 
heated in the blow-pipe with nitrate of cobalt. The blue colour 
produced is certainly very difierent to that developed when alumina 
is present. A bead consisting of phosphates of soda, lime, and mag- 
nesia, gave a very dull grayish blue colour with the cobalt; but, 
when the slightest trace of alumina was added, a very bright and 
decided colour resulted. I have applied this test, therefore, to the 
mine salts before and after alum was taken in the food. In the first 
case, the blue tint was very undecided, or was not at all manifested; 
while in the last it was bright and distinct. 

At a time when I was taking home-made bread perfectly free 
from alum, I examined the urine. The ash was tested for alumina 
with nitrate of cobalt in the usual manner, but only a faint blue 
colour was produced. Immediately after evacuating the bladder 
(12 noon), five grains of alum were taken, dissolved in an ounce and 
a half of distilled water. At 6 p.m., about fifteen ounces of urine 
were passed. A portion of this was evaporated to dryness, and the 
residue incinerated and decarbonised. A small quantity of the ash 
was treated with nitrate of cobalt, and heated in the blow-pipe flame. 
The bead, on cooling, was of a very bright blue colour. This experi- 
ment was repeated, with the same result. A similar reaction is met 
with in a great many specimens of ash obtained from the urine of 
hospital patients. Although this is not a perfectly accurate test, it 
indicates the presence of alumina in some specimens of urine in 
which one would expect a salt of this base to be present; while in 
urine which was perfectly free from alumina, no indication of its 
presence was afforded by the test. I think, therefore, if the cobalt 
test be employed carefally, it is worthy of more trust than most 
chemists seem disposed to place in it. A further series of researches 



AND QUANTITATIVE ANALYSIS. 127 

is reqaired to prove the proportion of alumina removed in the urine 
to that which escapes by the intestinal canal, when salts of this base 
are taken with the food. But I think there can be little doubt that 
a certain amount of this substance is really carried off in the urine. 
The urine salts of most persons give a very decided reaction indi- 
cating the presence of this substance, a considerable quantity of 
which is taken with many kinds of bread. Although there are many 
objections to mixing alum with the bread, and the practice ought 
clearly to be put an end to, I am not aware that any deleterious 
effects have been produced by its introduction. Some have attributed 
habitual constipation to this cause. 

It is desirable that the student should be acquainted with the 
principal characters of the most important inorganic salts of urine; 
and it has been considered desirable to give the following short course 
of systematic analysis. When it is required to estimate the pro- 
portion of chlorides, phosphates, or sulphates, quantitatively, the 
volumetric process will, however, be found the most accurate as well 
as the most expeditious. 

Systematic Qualitative or Quantitativb Analysis op 
Healthy TJbine: Inorganic Constituents. 

188. Analysis. — ^The portion of urine b, (p. 104), is also to be 
evaporated to dryness, and the dry residue incinerated in a large 
platinum capsule, and maintained at a dull red heat until it is 
perfectly decarbonised and nothing remains but an almost perfectly 
white ash. This, consisting of the fixed salts, is now to be examined 
as follows. Boiling distilled water is to be poured upon the saline 
residue, and the mixture thrown upon a filter. 

The solution oontams the alkaline salts. 

The insoluble matter, consisting of phosphate of lime, phosphate 
of magnesia, and silica, remains behind on the filter, 

t. The residue insoluble in water is to be treated with nitric 
acid, and boiled if necessary. Silica remains undissolved. If effer- 
vescence occur upon the addition of the acid, carbonate of lime was 
present in the ash. Filter; add excess of ammonia to the filtered 
solution, and redissolve the precipitated phosphates by adding excess 
of acelie acid. Next precipitate the lime as oxalate, by the addition 
of oxalate of ammonia. If the quantity of lime is required, the' 



128 SYSTEMATIC QUALITATIVE 

oxalate must be heated, exposed to the action of a dull red heat 
in a platinum capsule, and weighed as carbonate. 

After the separation of the oxalate of lime by fQtration, con- 
centrate the clear solution by eva^ration, and add a little ammonia 
and chloride of anunonium. Stir the mixture, and set it aside, that 
crystals of triple or ammonicuxM/Mgnesian phosphate may form. 

2. The original solution, containing the urinary salts, soluble in 
water, is divided into two portions, 2 a, 2 b, 

2 a. The first portion is acidified with nitric acid, and treated 
with nitrate of silver. Chloride of silver, indicating the presence 
of chlorine, is precipitated. The chlorine originally existed in 
combination principally with sodium. 

2 b. The second portion is also to be acidified with nit^c acid, 
and an excess of solution of nitrate of barytes added; a precipitate 
of stUphate of barytes, proving the presence of sulphuric acid, 
occurs. 

The mixture is boiled and filtered; and, upon the addition of 
ammonia to the solution, phosphate of baryta, showing the presence 
of phosphoric acid, is precipitated, care being taken to prevent the 
formation of carbonate of baryta by exposure to the air. 

Next the phosphate of baryta is to be separated by filtration; and 
the solution, which contains nitrate of barytes, ammonia, and the 
fixed alkalies, is to be concentrated. Excess of carbonate of ammonia 
and ammonia is to be added, and the mixture thrown upon a filter. 
The solution is to be concentrated by evaporation, and the barytes 
separated by sulphuric acid, after which the solution is to be 
evaporated to dryness, and the residue heated to redness in a hard 
glass tube, in the mouth of which a fragment of carbonate of 
ammonia has been placed. The residue is to be treated with water, 
and filtered. The solution contains the salts of the alkalies, potash 
and soda. The former is thrown down in the form of minute 
octohedral crystals of the potassio-chhride of platinum, upon the 
addition of a solution of bichloride of platinum. After stirring, 
these may be filtered off". 

The solution contains the sodio-chloride of platinum. It is to be 
concentrated, in order that the beautiful acicular crystals of this 
substance may form. 

The presence of the following substances in the specimen of urine 
submitted to examination, has been proved: 



AND QUANTITATIVE ANALYSIS. 129 

Fixed Salts ^ 

liime -....-....-... 

Magnesia ^. 

Potash _ 

Soda 

Chlorine 

Phosphoric Acid 

Sulphuric Acid 

The constituents not included in the above list, and in that on 
p. 106, require special processes for their demonstration; and, as 
many of them exist in very minute quantity, it is not desirable that 
the student should attempt to test for them in the small amount of 
urine usually operated upon. The substances alluded to are the 
following : — 

Creatine. Ammonia. 

Creatinine. Hippuric Acid. 

Sarkine. Iron. 

Uraematine. Alumina.* 

Uroxanthine. Carbonic Acid. 

Phenylic Acid ) « Leucine ) x 

Damaluric Acid ) Tyrosine ) 

Traces of Sugar. 1 

The characters of several of these have already been discussed, 
and the methods for separating them from the urine described. 

* Not necessarily present in healthy urine. 

t In urine in certain diseases. Probably not in healthy urine. 



Q 5 



180 



CHAPTEE VIII. 



Composition of Healthy Urine, and the Quantity of the 
Different Constituents excreted in Twenty -four 
Hours. — Aimlyses of Healthy Urine — Total Quantity in 
twenty 'four hours — Quantity in proportion to a given 
weight of the body — Variation in Quantity at different 
ages — Average Composition of Healthy Urine — Observations 
on estimating the Excrementitious Matters — Weighing 
Machines. 

184. Averafire Composition of Healthy Urine.— It is clearly 
very important that we should form a general idea of the quan- 
titative composition of healthy urine, and the amount of the various 
constituents which are excreted from the healthy organism in 
twenty-four hours. Those who are making observations on the 
urine in disease, should be acquainted also with the relative pro- 
portion of these different substances to each other. It is true that 
the healthy variations are very great; but, in certain cases of 
disease, the difference in the quantity is so considerable that the 
observer cannot fail to be struck with the importance of the fact. 
Thus, in health, from 400 to 500 grains of urea are excreted in 
twenty-four hours. In certain cases of kidney-disease, when the 
cortical portion is impaired in structure, not more than 100 grains 
are eliminated; while, in some cases of fever, upwards of 1,000 
grains have been removed in the same time. Of the significance of 
such facts there can be no question; and the physician cannot fail to 
reflect upon the very different chemical conditions under which life 
is being carried on in these cases. Without considering all the 
circumstances likely to affect these abnormal processes, how can we 



HEALTHY URINE. 



131 



hope ever to gain that insight into the nature of disease which, in 
many instances, can alone enable us to modify or counteract the 
morbid changes going on ? 

186. Analysis of Healthy XJrixie.— The composition of healthy 
urine is given in analyses by Berzelius, Lehmann, and Dr. Miller. 

A is an analysis of 1,000 parts of healthy urine by Berzelius ; b is 
one by C. 6. Lehmann. 



Water 


93300 




932019 


^ 


Solid matter 


67-00 


100-0 


67-981 


100-0 


Urea 


30-10 


44-9 


32-909 


48-4 


Uric acid 


1-00 


1^4 


1-098 


1-5 


Lactic acid .... 






1-513 


2-3 


Lactates .... 
Water extract 


. 17-14 


25-5 


1-732 
•632 


2-6 
1-0 


Spirit and alcohol extract 






10-872 


16-0 


Chloride of sodium .... 


4-45 


2-2$ 


3-712 


5-5 


Chloride of ammonium . 


1-50 


Alkaline sulphates . . . . 


6-87 


10-2 


7-321 


10-8 


Phosphate of soda . . . . 


2-94 


4-3 


3-989 


5-9 


Biphosphate of ammonia 


1-65 


2-4 






Phosphates of lime and magnesia . 


1-00 


1-4 


1-108 


1-7 


Mucus 


•32 


-4 


•110 


-3 


SiKca 


•03 


•04 







The following is an analysis of healthy urine by my friend 
Dr. W. A. Miller, of King's CoUege :— 



100-00 

33-00 

•86 

29^03 

5-80 

•37 

16-73 

4-91 

3-94 

•49 

•28 

4^47 

•12 



Specific gravity 






1,020 


Water .... 






956-80 


Solid matter . 






43-2 


/Urea . 






14-23 


Organic 
29^79 


Uric acid 






•37 


Alcohol extract 






12-53 


Water extract 






2-50 




Mucus . 






•16 


'Chloride of sodium 






7-22 


Phosphoric acid 






2-12 


Fixed Sulphuric acid 






1-70 


salts, •{ Lime . 






•21 


13^35 Magnesia 






•12 


Potash . 






1-93 




^Soda . . . 






•05 



186. Total Quantity of Substances excreted in Twenty-fonr 
HonxB. — But it is most important to be acquainted with the total 
quantity of the different ingredients excreted in twenty-four hours. 



132 AVERAGE QUANTITT 

The urine passed during the entire period of twenty-four hours 
should be collected and measured. From the results obtained, by 
analysing a portion of this, the total quantity of the different 
ingredients in the whole amount passed is easily calculated. The 
quantities of the different substances excreted in twenty -four hours, 
is stated under their proper heads, and a rough approximation of 
each is given in the table on p. 136. 

Vogel gives the following estimate of the quantity of urine and 
its most important constituents excreted in twenty-four hours in a 
state of health : — 



Average quantity in twenty-four hours 
Average specific gravity . 
Average quantity of urea 
Average quantity of chlorine . 
Average quantity of free acid . 
Average quantity of phosphoric acid 
Average quantity of sulphuric add . 



52| to 56 oz. 
1-020 

556 grainsL 
154 „ 

33 „ 

66-7 „ 

30*88 „ 



187. Proportion excreted for each pound weiflrlit of the Body. — 

The relation of the quantity of urinary constituents excreted, to the 
weight of the body, is also a most important inquiry, and is generally 
stated at so much for each pound weight. 

The following results, taken from Dr. Farkes, give the quantity 
of urinary constituents excreted for each pound weight of the body 
in twenty-four hours, adopting 145 lbs. as the average weight of aU 
the men whose urine had been analysed. 

Water 158639 grains. 

Urea 3*530 „ 

Uric Acid '059 „ 

Creatine *032 ., 

Creatinine •048 „ 

Pigment and Extractives .... 1*062 „ 

Sulphuric Add •214 „ 

Phosphoric Acid *336 „ 

Chlorine -875 „ 

The table below is taken from a valuable paper by the Rev. S. 
Haughton, in the " Dublin Quarterly Journal,'^ October, 1862. The 
results accord very closely with those just given. 



OF HEALTHY URTHE. 



133 













Excreted in 24 


Excreted in 




Hours per pound 


24 Hoots. 




of the body 
Weight. 


Urine 23021*25 grains. 


155-348 grains. 


Water . 






22063-44 


n 


148-881 „ 


Solid Matter . 






957-81 


n 


6-467 „ 


Urea . 






493-19 


M 


3-331 „ 


Uric Acid . , 






3-15 


n 


0-021 „ 


Phosphoric Acid 






32-36 


n 


0-218 „ 


Sulphuric Acid 






31-55 


n 


0-214 „ 


Chlorine . 






106-56 


n 


0-673 „ 


Extractives 






175-27 


a 


M83 „ 


Balance (viz. inorgan 


ic has 


es) 


115-73 


n 


0-827 „ 



188. Variation of Quantity at different periods of life. — The 
proportion of the diffeitent constituents excreted varies, however, as 
already stated, at different periods of life. The amount of urine 
excreted, is much greater in proportion to the body weight in chil- 
dren, than in adults. In the foetus and infant, however, the urine 
contains a very small quantity of solid matter. In a specimen of 
foetal urine, examined by Dr. Moore (Heller's pathology of the urine), 
no urea was present. I found urea in a specimen taken at the 
seventh month. It contained also numerous casts of the uriniferous 
tubes with free epithelium but no albumen. The proportion of solid 
matter is not more than five parts in 1,000. 

In young children of from 4 to 8 years, the mean age being 4 
years and 2 months, and the mean weight 31 lbs., the quantity and 
composition as calculated from analyses by Scherer, Bischoff and 
others, by Dr. Parkes, is as follows : — 













Per lb. of the 




In 24 Hours. 




body weight in 24 
Hours. 


Water . 


. 10062-0 


grains = 


=f s 


xxiij. 


3282-00 grains. 


Solid Matter . 


426-0 


» 






13-70 „ 


Urea . 


178-8 


» 






6-77 „ 


Extractives 


60-7 


5> 






1-96 „ 


Fixed Salts . 


186-9 


n 






6-03 „ 



In old age, on the other hand, the solids of the urine are consider- 
ably lessened. According to Lecanu, only 125 grains of urea were 
excreted in twenty-four hours by old people. The uric acid was 
about the ordinary proportion. 



134 AVERAGE COMPOSITION OF 

Although, in all works on the urine, t^kbles of the average com- 
position of urine are given, it must not be supposed that the 
numbers given' are true for every individual case. It has been 
clearly shown, not only that the proportion varies according to the 
weight of the person, the quantity of food taken, the amount of 
active excercise, and many other circumstances, but that the propor- 
tion of solid matter excreted for every pound weight of the body 
varies considerably in different individuals, in the same person at 
different times, and enormously at different periods of life. This, 
however, is no more than would be expected, since the proportion of 
the most important of the solid urinary constituents depends directly 
upon the quantity of matter disintegrated in the organism; and 
this, as is well known, is much greater in the child than in the 
adult; while in old age these changes are reduced to a minimum. 

189. Ayeraere Oomposition of Healthy Urine, &o.~With a 
view of giving a rough idea of the general amount of the different 
urinary constituents excreted, and the proportion which these bear 
to each other, in twenty-four hours, I have arranged the results of 
numerous observations in a tabular form. The proportion of some 
of these substances is so variable, that it is impossible to give an 
average. In most cases, I have purposely given a round number, 
and avoided fractional parts; but in other instances, in which I have 
not been able to institute examinations for myself, and when the 
question has only been examined by one or two observers, I have 
given the exact figures published by the authority who has made the 
matter an object of special study. In constructing this table, I have 
not attempted to follow any single observer, but, with the exceptions 
alluded to, have put down numbers which appear to me to be 
tolerably correct. They have been obtained by consulting numerous 
authorities, and from my own analyses. This table, therefore, is only 
to be looked upon as a rough approximation to the truth. In the 
second column will be found the quantity of each constituent 
corresponding to every pound weight of the body eliminated in 
twenty-four hours; in the third column the composition of 1,000 
grains of urine is given; in the fourth, the quantity of constituents 
in 100 grains of solid matter; and in the fifth, the percentage 
composition of the salts. 

The figures in the table may be regarded as the proportion 



HEALTHY UBINE. 135 

excreted by a strong heaJthy man in good nutrition, on inll diet. 
Healthy women would excrete from one-third less to half the 
quantities given in the first column. 

Some exception may be taken to the numbers expressing the 
rdative amount of the different ingredients. For instance, the pro- 
portion of urea to extractive matters undergoes the greatest variation. 
Sometimes the urea is double the weight of the extractives, while 
in other cases the numbers would be almost reversed. Many of the 
saline constituents also exhibit the greatest variations, not only 
in different individuals, but in the same person, on different days. 
Thus the quantity of chlorides is twice as great on some days as on 
others; depending, as before remarked, partly on the amount taken 
in the food, partly upon the quantity of fluid and other saline 
matters. As yet, these extraordinary fluctuations have not fully 
been accounted for; but, doubtless, in time, the circumstances which 
determine them will be accurately made out. 



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WEIGHING MACHINES. 137 

190. Observations on Estimatiner the Ezorementitioas Snb- 
stancea— The above table may, perhaps, assist the practitioner in some 
measure, in remembering the general composition of healthy nrine, 
and the proportion of the different constituents eliminated from the 
body in twenty-four hours. It is, however, quite impossible to use 
this or any other table as a standard of reference, because the 
proportion of the urinary constituents secreted in health is very 
different in different individuals. Before we can judge if a man is 
passing too much or too little of any substance, we must ascertain 
his weight, and form some general idea of the activity of his vital 
actions when he is in a state of health. For example, the statement 
that a patient is passing daily 150 grains of urea, indicates nothing; for 
a small woman in good health, weighing 80 lbs. or less, secretes daily 
even less than this; but if this amount only were excreted by a tall, 
strong, active, healthy man, weighing 170 lbs. or more, it would 
indicate a very serious condition, and we should know from 
this fact alone that he was in the greatest danger. The secreting 
structure of his kidneys must be temporarily or permanently affected, 
and, unless relief could be afforded very soon, death would probably 
result from the accumulation of excrementitious substances in the 
blood. If it is proposed to conduct a series of researches with the 
object of ascertaining the proportion of excrementitious substances 
produced in, and removed from, the organism, the weight of the 
individual should always be taken, and the amount of ingesta must 
be estimated daily. The quantity of excrementitious substances 
generally, including the sweat, if possible, must be estimated. There 
is very much to be made out by carefully conducting series of 
researches of this kind in the cases of patients suffering from various 
acute affections; and, since the introduction of the volumetric 
process of analysis, we have had great facilities for conducting such 
inquiries. 

101. Weigrhiner lCachines.~In many cases, the most valuable 
information bearing upon the progress of the case may be gained by 
the simple process of weighing the patient, which is too seldom 
adopted. All our hospitals and public institutions ought to be 
furnished with weighing machines. How often in the course of 
many diseases one desires to know simply if the patient has gained 
or lost in weight? The best weighing machines are, unfortunately, 



138 

very expensive. A good simple apparatus, which can be made for a 
moderate sum, is much required. Messrs. Weiss construct an 
improved apparatus suitable for the practitioner, but the price of 
this is ten guineas. Mr. Young of Cranboume Street, W.C., also 
makes excellent weighing machines. A very useful machine is 
supplied by Messrs. Pooley, of Liverpool, and Fleet Street, Lon- 
don, which is well adapted for ordinary observation, and costs less 
than four pounds. 



139 



CHAPTEE IX. 



Urine in Disease. — Diathesis. — ^Excess or Deficiency of 
Water and the Organic Constituents present in Health. 
Excess of Water — Diabetes Insipidus — Deficiency of Water 
— Clinical Remarks on t/ie increased Acidity of C/rine-^ 
Nitric Acid in the Urine — Alkaline Urine — Urcemia — 
Ammonia — On Detecting Urea in the Blood or Serum — 
On Detecting Ammonia in the Breath — Urea — Excess of 
Urea — Clinical Observations — Deficiency of Urea — Colour- 
ing Matter — Tests for Uroxanthine — Colouring Matter of 
the Blood — Black Pigment — Excess of Uric Acid and 
Urates — Treatment — Hippuric Acid — Extractive Matters 
— General Remarks on the Increase of the Organic Consti' 
tuents — Analyses of Urine in Skin Disease — Analyses of 
Urine in Chorea. 

Ubinb in Disease. 

182. Morbid Urine. — ^Before I describe in detail the particular 
characters in which a specimen of urine may differ from the secretion 
in its normal state, it is desirable to consider one or two questions 
of general interest, which can be more advantageously discussed here 
than in a future chapter. 

Many alterations in urine, which have been termed "morftw?," 
really depend upon increased or diminished activity of the same 
chemical changes which occur in health. It is often very difficult 
to decide how far an alteration in the quantity or quality of the 
constituents should be attributed to physiological changes, or referred 
to morbid actions; and it is quite impossible to separate by a distinct 
line, healthy from morbid actions. An excess or deficiency of the 
ordinary normal changes may lead to disease. There are many 



140 URINE IN DISEASE. 

alterations in the urine, depending upon a temporary derangement 
of those actions which occur in a state of health, which would not be 
properiy described under the term healthy, but which, nevertheless, 
cannot properly be called morbid. I do not attempt, therefore, to 
divide accurately healthy urine from morbid urine, and only wish 
the arrangement adopted in this work to be regarded as a sort of 
rough artificial division, adopted for convenience alone. Indeed, all 
such divisions are quite artificial; and no one attempts to assign 
accurate limits even to large and important branches of natural 
science, as anatomy, physiology, histology, botany, medicine, surgery, 
&c., which, merely for convenience, are treated of as separate 
subjects. 

Important changes often occur after the urine has been passed, 
and may be due to the action of the air, fermentation caused by the 
presence of mucus, and a number of other circumstances. 

The functions of digestion, respiration, and circulation, are 
intimately concerned in the formation of those substances which are 
removed from the system in the urine. The characters of the 
secretion are much affected by the state of the skin and the action 
of the liver; and there are many other circumstances which may 
cause an alteration in the urine, independently of those numerous 
affections to which the urinary organs are exposed. Disease of the 
secreting structure of the kidney, or of any part of the complicated 
and extensive efferent channel by which the urine is carried off from 
the gland, may cause very important alterations in the characters of 
the secretion. It is of great importance to us, as praxititioners, to 
know that an examination of the urine may materially assist us in 
endeavouring to ascertain the exact nature and precise seat of the 
derangement in cases of renal disease, and of the mucous surface 
and organs connected with the urinary apparatus. Sometimes we are 
able to diagnose the morbid alteration from an examination of the 
urine alone ; but in almost all cases such an examination will afford 
important information bearing on the nature of the case. Certain 
substances, which are ordinarily eliminated in the urine, may, in 
consequence of morbid actions having been set up, be attracted to 
other parts of the body, or be eliminated through other channels. 

When the kidney itself is affected, the morbid condition may be 
temporary or permanent; and this can often be ascertained with 
certainty by examining the urine. The mucous membrane of the 



DIATHESIS. 141 

pelyis of the kidney, of the ureter, or of the bladder, may be the 
seat of the lesion ; or lastly, a certain effect may be produced by the 
growth of adjacent tumours, by causing pressure, altering the 
structure of the organs, <fec. 

The ordinary constituents may be in greater or less proportion 
than in health, or certain soluble substances not met with in the 
healthy secretion may find their way into the urine. As I have 
before remarked, a little mucus from the urinary passages is the 
only deposit which occurs in health. In disease, insoluble deposits 
are commonly met with. Substances which are comparatively, 
though perhaps not absolutely, insoluble (being soluble in a very 
large quantity of the secretion), may float upon the surface of the 
urine, or may be suspended throughout the fluid. 

By microscopical examination, combined with chemical tests, 
the nature of a deposit is made out. By chemical analysis alone, an 
abnormal proportion of substances present in health, and the 
presence of such as are not found in the healthy secretion, can be 
detected, and the amount estimated. 

The various alterations of the urine in disease will be discussed 
in the following order. 

First, excess or deficiency of any of the normal constituents of 
mine. Secondly, I shall refer to the characters of certain soluble 
substances in the urine in disease, which are never met with in a 
state of health. The subject of urinary deposits will be subsequently 
considered. 

Diathesis. 

198. Diathesis.— The word diathesis is very frequently used in 
connection with certain abnormal states of the urine. Before 
considering the characters of the urine in disease, it is therefore 
desirable to discuss what is understood by this word. The " uric 
acid," the " phosphatic," the " oxalic," the " sulphuric " diatheses, 
and others, are constantly spoken of It is well to consider whether 
any real advantage is gained by employing this term in the manner 
in which it is generally used. Although the word has been 
employed by very high authorities since the time of Dr. Prout, 
there is great objection to its use as an explanation of the causes of 
the production of urinary deposits. 

In the first place, with reference to the uric add diathesis ; this 



142 PHOSPHATIC, SULPHURIC, 

term has been applied to all cases in which the urine habitually 
contains deposits of uric acid and urates. The precipitation of uric 
acid in an insoluble form is due to a change taking place in the 
urine, at least in the majority of instances, after it has been 
secreted. Excess of uric acid may exist in the urine in two states, 
dissolved in the fluid, and in the form of an insoluble deposit. In 
the first case, the practitioner would not be cognizant of the excess ; 
and a person may be passing a very considerable quantity of urates, 
in a state of solution, for a long time, without any notice being 
taken of the fact. On the other hand, a patient's urine may 
contain only the healthy proportion of uric acid ; but this, owing to 
a change taking place aft^ it has left the bladder, might be 
deposited in an insoluble form. From this circumstance alone, it 
would be inferred that the last patient had a disposition to the 
formation of a large quantity of uric acid {urio acid diathesis), 
while really there might be a much larger amount produced and 
excreted in the former instance. 

Secondly; persons whose urine has deposited triple phosphate 
and phosphate of lime have been said to suffer from the phosphatic 
diathesis ; while the deposition of the sediment depends, at least in 
the great majority of cases, upon a change occurring in the urine after 
it has left the secreting part of the organ, and has not necessarily 
anything to do with the habit of body or peculiarity of constitution, 
or with the state of the blood. But the deposition may be associated 
with actual and positive excess. Dr. Bence Jones defines the phos- 
phatic diathesis and the sulphuric diathesis in the following terms : 
— " What I wish to impress upon you now is, that the true phos- 
phatic diathesis — that is, the occurrence of an excess of alkaline 
and earthy phosphates in the urine — ^may not make itself apparent 
to the eye. The alkaline phosphates may be present in an inordinate 
excess; and, as in the sulphuric diathesis, the sulphates may be 
immensely increased," &c. (Lectures on Digestion, Respiration, and 
Secretion, ^^ Medical Times and Gazette J"* March 27th, 1852.) 

Now, in these cases, what is observed is, that a greater propor- 
tion of certain constituents is excreted in the urine than occurs in 
perfect health. The different physiological conditions under which 
an excess of some of these substances is produced are well under- 
stood, and the result cannot be referred to any peculiar habit or 
diathesis. If we speak of the sulphuric acid diathesis, we must, of 



AND OXALIC DIATHESIS. 143 

course, admit the urea diathesis ; for usually, wlien the sulphates 
are in excess, a corresponding increase in the proportion of urea 
exists. On the same principle, we might speak of the extractive 
diathesis and the water diathesis. It would be quite as fair to talk 
of the carbonic acid diathesis when an increased proportion of car- 
bonic acid was exhaled, <fec. 

Thirdly; many of the above remarks will apply to the so-called 
oxalic diathesis. The presence of oxalate of lime, and the increase 
of certain of the materials which exist in health, depend upon the 
action of well-known chemical changes, and result as the natural 
consequence of confinement, exposure to cold, particular kind of food, 
&C. No peculiar diathesis can be discovered in persons who pass 
urine having these characters : in fact, in the majority of cases, the 
alteration is only of temporary duration ; and it therefore seems to 
me, that the term diathesis is quite inapplicable. 

We may in the present state of knowledge, with propriety, 
perhaps, speak of the gouty diathesis* of the tubercular and cancerous 
diathesis, and, perhaps, of the rheumatic diathesis, because there 
certainly is a peculiarity of constitution, which may be transmitted 
from parent to offspring, and which is characterised by the invariable 
presence of certain morbid actions which exist in the conditions 
familiar to us, under the terms gout, tubercle, cancer, and rheumatism. 
But of the actual state of the blood, and condition of the vital 
processes, which lead to the symptoms with which we are so familiar, 
we really know very little; so that it seems to me better, even in 
these cases, to say that a patient suffers from attacks of gout, of 
tubercle, cancer, or rheumatism, than to hide our ignorance of the 
essential nature of these morbid states under a learned term, the 
meaning of which cannot be well defined. I shall venture then 
to discard altogether the use of the word diathesis in the discussion 
of morbid states of the urine. 

Excess or Deficienct of Water aitd of the Oroanic 
Constituents of Urine. 

, 194. Water.— The varying quantities of water removed from the 
body, in different physiological states of the system, have been 

* Dr. Qarrod has shown that, in gont, the kidney fails to excrete the uic acid in 
the oBoal quantity. 



144 DIABETES INSIPIDUS. 

already referred to. Every one is familiar with the relations 
existing between the functions of the skin and intestinal canal, and 
the kidneys. The same laws hold in disease. If the kidneys be 
diseased, and the intestinal canal, the skin, and the respiratory 
apparatus, be tolerably healthy, they, to some extent, fulfil the work 
of the kidneys. In skin diseases, and in certain affections of the 
intestinal canal, increased work is thrown upon the renal apparatus. 
In the treatment of these cases, the practitioner must bear in mind 
the existence of such relations. 

There are certain affections in which the quantity of water 
removed from the body is greatly increased. In various hysterical 
and other emotional states, large quantities of pale urine, con- 
taining but a small quantity of solid matter, are frequently 
voided. Some persons habitually pass very dilute urine, which is not 
very easily explained, but is probably to be looked upon as an 
individual peculiarity, corresponding to the constant sweating, and 
to the unusual amount of action of the alimentary canal, occasionally 
met with in individuals who enjoy good health. 

It has been already remarked, that within certain limits water 
increases the disintegration of tissue; and when a large amount of 
fluid is taken, the total quantity of solids removed in the urine is 
greater than in health. When the solids as well as the water are 
greatly increased in quantity, we should be led to fear the existence 
of diabetes (Chapter XII.). An unusual quantity of urine of very 
high specific gravity, and therefore containing a large amount of 
solid matter, is almost characteristic of this condition. 

196. Diabetes Insipidus. — The majority of the so-called in- 
stances of diabetes insipidus are cases in which there is great 
thirst, and a large amount of water is removed from the kidneys 
daily (diurem); but the total quantity of solid matter is not above 
the normal standard. In a few of the cases recorded, it would 
appear that the latter is also much increased ; but these must be 
very rare. There is no sugar in these cases. I have seen instances 
in which the quantity of water passed as urine was two or three 
times as great as that said to have been taken in the food ; but I 
firmly believe that deception was practised, and that the patient got 
water by stealth. In some cases, however, in which very large 
quantities of urine are voided, there is undoubted evidence of 



DIABETES INSIPIDUS. 145 

cliroiiic renal disease. In Vol. II. of my ^^ Archives," Dr. Bade 
alludes to several cases of this disease, and gives notes of two which 
occurred in men of the ages of 65 and 40. Two of the cases were 
children. The urine passed by the men amounted to from five to 
seven pints. Its specific gravity varied from 1,003 to 1,014. The man 
aged 65 suffered from severe irritation of the bladder, and died in 
eighteen months. The post mortem revealed a bloodless state of the 
viscera generally. The coats of the bladder were much thickened ; 
the infundibula and pelves of the kidneys much dilated ; the left 
kidney was of the natural size; the right, one-half larger, the cones 
very hard, pale, and flaccid. In the other fatal case, both kidneys 
were much wasted. Th^ cones "converted into dense fibrous tissue, 
containing many large cystiform spaces"; the pelves much enlarged, 
and the ureters a little dilated. Both supra-renal bodies were 
"converted into flaccid cysts, capable of containing each some half- 
ounce of fluid, with their walls having a bile-coloured granular 
appearance." Dr. Eade sent me the kidneys for examination. I 
found that many of the tubes in the cortical portion were narrow 
and much wasted ; others were twice the diameter of the tubes in 
health. The walls of the tubes were thick and firm; the Malpighian 
bodies were smaller than in health; the epithelial cells smaller and 
more numerous. The state of the supra-renal bodies in this case has 
led Dr. Eade to offer the suggestion, that the condition might have 
originated in some irritative disorder of the supra-renal bodies. 
(''Archives of Medicine;' Vol. III., p. 127.) 

The following analysis represents the composition of the urine in 
one of these cases of Hydruria, or diabetes insipidus. It was obtained 
from a man aged 45, in King's College Hospital, under Dr. Todd. 
This patient was passing about eleven pints of urine per diem, 
while he was drinking about thirteen pints of liquid. Reaction 
feebly acid; specific gravity 1002*8. 



Water . 


Analysis 1. 
. 995-91 




In 24 hours. 


Solid Matter . 


4-09 


100-00 


394 


Organic Matter 


2-79 


68-22 


268 


Fixed Salts . 


. . 1-30 


31-78 


125 



The quantity of urea excreted in twenty-four hours in this case was 
very small, which confirms the observation of Bischoff, that the 



146 DIABETES INSIPIDUS. 

ingestion of a large quantity of water diminishes the excretion of 
urea. At first, the total quantity passed in twenty-four hours is 
above the average, because much is washed out from the tissues by 
the large quantity of fluid ; but afterwards it falls, because less is 
formed in the organism than under ordinary circumstances. The 
proportion of inorganic salts to the organic constituents of the urine 
is very high, though the total quantity is less than is passed in 
health. 

In one of Dr. Eade's cases, an analysis of the urine was made by 
Mr. Sutton. It contained only 93 grs. of solid matter in 1,000 grs.; 
of this, 5*57 grs. consisted of urea. The composition of 100 grs. of 
the solid residue was as follows : — 

Analysis, 

Urea 60-00 

Potash 5-63 

Lime *49 

Soda and Magnesia 11*14 

SiHca -43 

Anunoniacal Salts, &c 8*62 

Sulphuric Acid 3*07 

Phosphoric Acid 2*97 

Chlorine * 7*66 

Dr. Strange, of Worcester, has published a very interesting case 
of diabetes insipidus. {"Archives of Medicine,^'' Vol. III., p. 276.) 
The patient was a boy aged 18, with excessive thirst. He was of 
small build, but moderately stout. The urine amounted to twelve 
pints in twenty-four hours, and this large quantity had been passed 
for years. The specific gravity was 1,007. There was no albumen 
or sugar. The complexion was ruddy, and there was no pallor or 
puffiness indicative of renal disease. On admission into the infirmary 
he was only allowed a limited quantity of fluid to drink, and he 
was treated with phosphoric acid and nux vomica. Catechu and 
laudanum were afterwards given to restrain the diarrhoea from 
which he was suffering. About ten days after admission he became 
drowsy. A fortnight after admission he was seized with convulsions, 
and soon became comatose, with dilated pupils and stertorous 
breathing. The insensibility passed off after he was bled, but again 
recurred two days afterwards, and soon became profound. He died 



TREATMENT. 147 

with symptoms of cerebral efiiision. Both kidneys were reduced to 
"mere sacs, of from twice to thrice the extent of the healthy kidney ! 
There was complete absence of all proper parenchymatous structure, 
both tubular and cortical, the sacs being divided into a number of 
cells by the septa which occur in the foetal state/' The circumference 
of the ureters varied from three to four-and-a-half inches, No urea 
was found in the fluid in the ureters and sacs. Dr. Strange con- 
siders that the condition of the kidneys was mainly due to con- 
genital malformation. He thinks it probable that the sacs were 
only capable of separating the urea from the blood when in a very 
dilute form, and considers that the diarrhoea and the diminished 
quantity of fluid ingested may perhaps have somewhat hastened the 
fatal result. In all cases of this condition, there is an abundant flow 
of urine, depending upon the sufferers being excited to drink largely 
to allay the excessive thirst which they experience. There are 
languor, debility, loss of appetite, often nausea and vomiting, with 
weak heart's action, and general loss of power, and sometimes an 
irritable state of bowels, with diarrhoea. It is certain that many 
very important points connected with this very interesting disease 
are yet to be discovered. Every case should be very carefully 
observed. 

196. Treatment.— Two of Dr. Eade's cases improved under tonics 
and iron.. The quantity of fluid allowed should be reduced very 
cautiously. Dilute mineral acids, especially phosphoric acid, some- 
times allay the thirst. The state of the patient's health generally 
must be considered ; and if chronic renal disease exists, the treat- 
ment must be conducted according to the general plan followed in 
this condition. Of all mere remedies, the greatest benefit results 
from the tincture of sesquichloride of iron, steadily persevered in for 
months. But the practitioner will, of course, study the whole state 
of the patient, and not attempt merely to diminish the excessive 
diuresis. 

197. Deficiency of Water is, in the great majority of cases, 
associated with an abnormal quantity of solid matter. The ingre- 
dient which is usually in excess, and to which the urine owes its 
great density, is urea ; so that urine of this character will be more 
conveniently considered presently. There are cases in which a very 
small quantity of urine, containing but a small percentage of solid 

H 3 



148 CLINICAL REMARKS. 

matter, is passed; bnt in these albumen is generally present, and 
they will be considered in Chapter XI. When the total amount of 
nrine is very small, and the secretion contains bnt little solid matter, 
the secreting structure of the kidney is generally much impaired. 

108. Clinical Bemarks on the Increased Acidity of TJrine. — 
The causes of the reaction of healthy urine have been already con- 
sidered in § 119, and it is therefore unnecessary to pursue this part 
of the subject further. Vogel states that, in chronic and acute 
diseases, the quantity of free acid is diminished for the most part. 
In many cases of pneumonia and rheumatic fever, however, the 
quantity of free acid is much greater than in health. 

A highly acid condition of the urine, persisting for a long period 
of time, may cause the precipitation of uric acid, and so lead to the 
formation of a calculus. Acid urine not unfrequently causes 
irritable bladder, and excites other morbid actions. In most cases, 
the salts of the vegetable acids (citrates, acetates, tartrates), will be 
found more efficient in counteracting this acid state of the urine, 
than alkalies or their carbonates, and are less likely to interfere with 
the digestive process. There are, however, low conditions of the 
system in which the acid state of the urine, and a tendency to the 
deposition of uric acid in large quantity, are not relieved by this 
treatment; on the contrary, such cases are often much benefited by 
an opposite plan of treatment — tonics and the mineral acids before 
meals, a nourishing diet, with a moderate supply of simple stimu- 
lants with a little alkali, or with alkaline waters. Pepsine is offcen 
of great use in these cases. Many of them seem to be intimately 
connected with impaired digestive power. The acid state of the urine 
may depend upon very different conditions of the system, and these 
must be carefully considered in each individual case before any plan 
of treatment is suggested. 

199. Nitric Acid in the TJrine.— Dr. Bence Jones {^^Philo- 
sophical Transactions" 1851, p. 399) has been led to the conclusion 
that ammonia, in its passage through the organism, gives rise to the 
production of a certain quantity of nitric acid, which is eliminated 
in the urine. He found that the acidity of the urine was not 
diminished by giving large quantities of carbonate of anmionia ; and 
that, in some instances, the acid reaction seemed to be increased. 



NITRIC ACID. 149 

While tartrate of potash soon rendered the urine alkaline, this effect 
was not produced by the corresponding salt of ammonia. 

The following test, suggested by Dr. Price, was employed for the 
detection of the nitric acid, in preferente to the indigo test. By 
this plan, one grain of nitrate of potash dissolved in ten ounces of 
urine was detected with the greatest ceriiainty. From four to eight 
ounces of urine were mixed with half an ounce of strong and pure 
sulphuric acid, free from nitrous acid. Two-thirds of the mixture 
were distilled over; and, after being neutralized with pure carbonate 
of potash, the distillate was evaporated to a very small bulk. From 
a drop, to half of the residue, was mixed with the following test- 
solution. To a solution of starch, a drop or two of a solution of 
iodide of potassium, specific gravity 1,052, and very dilute hydro- 
chloric acid, specific gravity 1,005 were added. If nitric or nitrous 
acid is present, the iodine is set free, and a blue iodide of starch is 
at once formed. 

Another portion of the residue was placed in a basin, and a very 
small quantity of indigo, with excess of sulphuric acid, added. If 
nitric acid was present, upon applying heat for a few minutes, the 
colour of course disappeared. 

From numerous experiments, varied in many ways. Dr. Bence 
Jones came to the conclusion that ammonia in the organism is partly 
converted into nitric acid. The nitrogen of the air also, in ordinary 
combustion, unites with oxygen to form nitric acid. Urea and 
caffeine, and other substances containing nitrogen, give rise to^the 
formation of a small quantity of nitric acid. Although Lehmann 
has failed to confirm these results, he has not, I think, succeeded in 
shaking the evidence in favour of the conclusions.* Dr. Bence Jones 
brings forward several cases of healthy persons whose urine did not 
yield a trace of nitric acid; but, three or four hours after they had 
taken carbonate of ammonia, evidence of the presence of the acid was 
afforded by the starch and also by the indigo test. After twelve 
hours, only a trace could be detected; and, in twenty-four, even this 
ceased to be perceptible. The urine was examined in precisely the 
same manner in every case. A small amount of ammonia in the 

* Professor Lehmann attributed the action upon the iodide of potassium to the 
presence of sulphurotts add. J&S6 x>erformed some experiments in Lehmann's laboratory, 
and obtained sulphurous acid but no nitrous acid from healthy urine and from urine 
passed after taking ammoniacal salts. Dr. Bence Jones has subsequently repeated his 
experiments, and finds that Jaffi^'s experiments do not invalidate Price's test for nitrous 
acid as Lehmann supposed. C Proceedings <^ihe Royal Society y'* VoL YIL, p. 94.) 



150 ALKALINE URINE. 

organism is converted into nitric acid; and it is not improbable that, 
under certain circumstances, the quantity of nitric acid formed in 
this manner may be very much increased. 

200. Alkaline TJrine. — An alkaline condition of the urine may 
be due to several causes, and requires, therefore, to be treated on 
different plans. The connexion between an alkaline state of the 
urine, depending upon fixed alkali, and the secretion of a highly acid 
gastric juice, has been already referred to. In such cases, attention 
must be paid to the state of the digestive process; and when this is 
set right, the urine will regain its normal characters. Dr. Bence 
Jones (^^Medico-Ohirurgiccd Transactions," Vol. XXXV.) alludes to 
three cases of dyspepsia with vomiting of a very acid fluid (two of 
them rejecting sarcinsB), in which the urine became alkaline from 
the presence of fixed alkali when the quantity of acid set free at the 
stomach was very great; but, when this was small, the reaction of 
the urine was acid. It must, however, be borne in mind that the 
very acid nature of the materials rejected in many cases of vomiting, 
and especially in cases of sarcina ventriculi, arises, not from the 
secretion of an acid fluid by the glands of the stomach, but from the 
decomposition or fermentation of the food when acids are developed, 
among which may be mentioned acetic, lactic, and butyric acids. At 
the same time, there can be no doubt that, in many cases of dyspepsia, 
the feebly acid or alkaline condition of the urine arises from the 
seoretion of an abnormal amount of acid by the stomach. "The 
degree of the acidity of the urine may, to a certain extent, be 
regarded as a measure of the acidity of the stomach." (Dr. G. 0. 
Rees, ^^Lettsomian Lectures^^ 1851.) 

Dr. Eees has drawn attention to a large class of cases in which he 
explains the alkaline condition of the urine as follows: — Urine which 
is highly acid at the time of its secretion, irritates the mucous 
membrane of the bladder, and causes it to secrete a large quantity of 
alkaline Jluid, This mucous membrane in health secretes an alkaline 
fluid, to protect its surface, just as occurs in the case of some other 
mucous membranes. Under irritation, more alkaline fluid than is 
just sufficient to neutralise the acid of the urine is poured out; and 
hence the urine, when examined, is found to have a very alkaline 
reaction. In such cases, this highly alkaline condition is removed by 
giving liquor potasssB or some other alkali, or a salt of a vegetable 
acid which becomes converted into an alkali in the system. The urine 



UILEMU. 151 

is not secreted so acid, and therefore does not stimulate the mucous 
membrane to pour out so much alkaline fluid. I know no obser- 
vations to disprove Dr. G. 0. Rees' explanation of the fact, that in 
some cases, alkalies cause the urine to become less alkaline^ or even 
restore its add reaction; yet one would hardly expect, if this be the 
true explanation in cases generally, that the natural reaction of 
urine would be acid. If there was danger of the healthy mucous 
membrane suffering from the contact of a fluid only a little more 
acid than that destined to be continually touching it, should we not 
expect it to have been of such a character as to resist this action like 
the mucous membrane of the stomach, instead of being excited to 
secrete a fluid of such a nature as might lead to its own destruction? 
Again, the mucous membrane of the bladder bears very well the 
contact of acid fluids which are sometimes injected; and patients 
sometimes for years pass intensely acid urine, without the secretion 
of this excess of alkaline fluid from the mucous membrane. 

201. TJreamia is the term applied to that condition of the sys- 
tem which soon follows the retention of excrementitious urinary 
substances in the blood. The condition generally results from long- 
continued organic disease of the kidneys, but it may depend upon 
acute disease. The nervous phenomena are generally considered to 
depend upon the accumulation in the blood of urea, but later 
researches have shown that neither urea, carbonate of ammonia, nor 
nitrate of potash, injected into the blood of animals, prove speedily 
fatal, unless the kidneys be previously extirpated (Hammond). If, 
however, the quantity of urea injected be very large, death does 
take place. Stannius, on the contrary, states that urea injected 
into the blood is harmless ; and Petroof has injected a large quantity 
into the blood without causing coma. Dr. Hammond has shown that 
the urine, as a whole, is more poisonous than a simple solution of 
urea. He has proved most conclusively that Frerich's notion — that 
the urea became decomposed into carbonate of ammonia — is erro- 
neous; and Johnson, Richardson, and others, are of the same opinion. 
Hoppe finds that, in uraemia, the extractives are increased to three 
times and the creatine to five times the normal amount. 

Dr. Richardson has shown that even water in excess in the blood 
will produce symptoms resembling those present in uraemia ("(7Zmt- 
cal Essay s^^ Vol. I., p. 171); but he agrees with most other observers 



152 AMMONIA 

in considering that the condition ar»mia depends npon the retention 
of urea in the blood, and its a<^ion upon the tissues of the body as 
a poison. 

In considering this question, it must be borne in mind not only 
that the renal disease has gradually advanced, and that the kidneys, 
have become almost inefficient, but that most important alterations 
have been slowly taking place in the blood. Many tissues in the 
organism have been secondarily affected, and are probably much altered 
in structure. At present, we are but very imperfectly acquainted with 
the normal changes occurring in the blood, or with the consequences 
immediately resulting to the tissues, especially the nervous system^ 
in consequence of the retention of certain excrementitious matters; 
and we know very little of the remote or immediate effects resulting 
from certain excrementitious substances not being formed at all. 
The question is a more difficult one than at first appears, and 
requires more searching chemical and microscopical investigation 
than it has yet received. The latest writer on this subject concludes 
a very elaborate essay thus : ** Enfin, cette alteration chimique du 
sang est encore mal d6finie, et la science attend sur ce point de 
nouvelles recherches." ("Z)« UUremie, TkeseJ^ par Alfred Foumier, 
1863.) At the same time^ it is quite certain that the accumulation 
of urea, and probably other urinary constituents, in the blood, will 
give rise to uraemia as soon as the proportion reaches a certain 
amount. This must occur if the formation of these substances 
proceeds, while, from their damaged state, the kidneys can no longer 
separate them. 

202. Ammonia.— Numerous experiments seem to show that in 
health a small quantity of ammonia escapes in the urine. Neubauer 
has conclusively proved that certain ammoniacal salts pass through 
the organism, and may be detected in the urine unchanged. 
Ammonia, as is well known, is very easily produced by the decom- 
position of the urea; but it is almost certain that a small quantity 
passes into the urine from the blood, independently of that derived 
from this source. 

In disease, the quantity of ammonia present in the urine is often 
so great as to be smelt all over the room in which the patient lies; 
but in these cases the ammonia arises from the decomposition of the 
urea after the urine has left the bladder, and in some it is 
decomposed even while it yet remains in this viscus. 



IN URINE, BLOOD, AND BREATH. 153 

It is doubtful if a large amount of ammonia under any circum- 
stances accumulates in the blood afterwards to be excreted in the 
urine, as it is probable that, if formed, it would escape more rapi41y 
from the lungs or intestinal canal. The doctrine that the coma 
occurring as a sequel to many cases of kidney-disease, depended upon 
the accumulation in the blood of ammonia produced by the decom- 
position of urea, was originally put forward by Frerichs. In some Of 
these cases of renal coma, ammonia is present in abnormal quantity. 
In others, neither urea nor ammonia can be discovered in the blood, 
while sometimes urea can be detected without difficulty. 

I have examined the serum in many cases for urea. Half an 
ounce of blister serum from a man suffering from renal coma yielded 
•54 gr. of nitrate of urea. The patient died shortly afterwards, and 
urea was detected in the blood and in the brain substance. In 
another instance, it was detected in the serum of a blister from q, 
man who had had one epileptic fit, depending upon renal disease. 
In the case of a boy, aged 18, who suffered from epileptic fits, I also 
detected it in blister serum; as well as in eight ounces of serum from 
a man suffering from acute dropsy of a week's duration; and I might 
refer to others in which I -obtained undoubted evidence of the 
presence of urea. There are, however, cases of the same cha- 
racter in which I failed to detect urea, or ammonia resulting from 
its decomposition. 

I have several times examined the breath of such patients, 
without being able to obtain indications of a larger quantity of 
ammonia than is afforded by healthy persons. I think, therefore, 
that we must admit that there are many cases of the so called 
urcemic poisoning which have not yet been satisfactorily explained. 
It may, however, be urged, that in many cases, although ammonia 
was formed, it might have been rapidly eliminated from the skin or 
intestinal canal, so as to escape detection. Bernard and Barreswil 
have performed some experiments which prove that, after extirpation 
of the kidneys, urea escapes into the intestinal canal in the form of 
an ammoniacal salt; and they found that it could not be detected in 
the blood in less than from twenty-four to forty-eight hours after 
the operation, when the animal had become weak and exhausted. 

Dr. Garrod has detected urea in the blood and blister serum of 
several cases of gout. (^^Med. Chur. Trans'^ 1848). His results 
have been confirmed by Dr. W. Budd, who has detected urea in the 

H 5 



154 DETEOTING UBEA IN BLOOD. 

blister seniin, in nine cases of acute gout, in wliich there was no 
indication of renal disease. {''Med. Chur. Trans:' Vol. XXXVIII., 
p. 242.) 

208. On deteotingr TTrea in the Blood or Seoram.— The urea 
may be detected by concentrating the serum, after adding a few 
drops of acetic acid, and extracting with strong alcohol, or the fluid 
may be evaporated to dryness, and the dry residue treated with 
boiling alcohol. The alcoholic solution is evaporated to dryness, 
treated with a drop of distilled water, and two or three drops of 
strong nitric acid allowed to fall into the syrupy solution. If urea i 
be present, crystals of the nitrate of urea are formed, and may be 
readily distinguished by microscopical examination. Crystals of 
nitrate of urea are represented in Plate XI., Fig. 55. 

204. On deteotinsT Ammonia in the Breath. — The method of 
examination which Dr. Richardson recommends is the following : — 
An instrument in the form of a straight breast-pump is employed to 
breathe through; a drop or two of hydrochloric acid is placed in the 
bulb, and a perfectly clean slip of microscope glass placed across the 
trumpet extremity of the tube, and secured by an India-rubber 
band. The alkali, as it passes over the bulb, combines with the 
acid, but some of the acid and alkaline vapours pass over together 
and condense on the microscope glass. As this becomes dry, crystals 
are formed (Plate XII., Fig. 65). In health, traces of ammonia are 
always found in this manner. 

205. TJrea.~From what has been already said with reference to 
the variations in the proportion of urea secreted, under different 
circumstances, in a state of health, it will be inferred that, in 
disease, the quantity of this constituent varies greatly. The total 
amount formed in a given time may be much greater or less than in 
health ; and the proportion which this substance bears to the other 
organic constituents varies greatly in different cases. 

206. Ezoess of TJrea.— The term "excess of urea" is not applied 
to those cases in which the total quantity excreted in the twenty- 
four hours is much greater than in health ; but a specimen of urine 
which yields crystals of nitrate of urea when an equal bulk of nitric 
acid is added to it in the cold, without having been previously con- 



EXCESS OF UREA. 155 

centrated, is said to contain "excess of urea." The quantity of urea 
dissolved in the fluid is so great, that a nitrate of urea is fonned, and 
crystallises just as if the urine had been concentrated by evaporation. 
This result may be brought about in several ways. In cases in which 
but a small quantity of fluid is taken in proportion to the urea to be 
removed — when an unusually large amount of water escapes by the 
skin and other emunctories — and in cases in which an unusual 
amount of urea h formed in the organism, we shall frequently find 
excess of urea in a specimen of the urine. 

Dr. Golding Bird has drawn attention to the frequency of the 
occurrence of excess of urea with oxalate of lime. The quantity of 
oxalate of lime, however, is in all cases so very small that it is hardly 
possible to believe that the formation of this substance can be very 
important. It will be shown that the oxalate is one of the com- 
monest urinary deposits; that it may result from decomposition of 
urates; that there is no reason for believing it to be indicative of 
any peculiar diathesis or habit of body. Excess of urea afibrds 
no explanation of the presence of oxalate of lime, nor this latter 
of urea. Each condition may exist without the other. Ceteris pari- 
bus, we should expect to find oxalate of lime most frequently present 
in specimens of highly concentrated urine. 

Excess of urea is frequently found in the urine of persons sufiering 
from acute febrile attacks. It is very common in cases of acute 
rheumatism, and is often met with in pneumonia and acute febrile 
conditions generally. In England, we meet with these cases very 
frequently; but, on the continent, they appear to be so rare that 
many authorities seem to doubt the truth of what English observers 
have stated with regard to this point. Lehmann, I think, states 
that he had not seen a case in which crystals of nitrate of urea were 
thrown down upon the addition of nitric acid, without previous 
concentration. 

The amount of urea excreted is often very great. Vogel mentions 
a case of pyaemia in which 1,235 grains of urea were removed in the 
course of twenty-four hours. Dr. Parkes obtained as much as 885 
grains in a case of typhoid fever. These quantities are very great, if 
the patients did not exceed the average weight of adult men; but, 
unfortunately, the weight was not recorded. 

Urine containing excess of urea is generally perfectly clear, of 
rather a dark yellow colour, and of a strong urinous smell. Its 



156 CLINICAL OBSERVATIONS. 

specific gravity is about 1,030, and it contains generally 60 or 60 
grains, or more, of solid matter per 1,000. At ordinary temperatures, 
an aqueous solution must contain at least 60 grains of urea per 1,000, 
to form crystals of the nitrate upon the addition of jiitric acid 
without previous evaporation; 60 grains of urea per 1,000 hardly 
gave the slightest precipitate after the lapse of a considerable time. 
It would seem that the salts, extractive matters, <fec., in urine, cause 
the crystallisation of the nitrate when even a smaller quantity of 
urea is present. It should be mentioned, that the above experiments 
were performed in the summer, in very hot weather. In one case, 
in which the urea readily crystallised on the addition of nitric acid, 
the urine had a specific gravity of 1,028, and contained — 

Analysis 2. 

Water 940*18 

Solid Matter 59*82 

Organic Matter .... 50*57 

Fixed Salts 9*25 

Urine containing excess of urea is generally acid, but I received 
a specimen from Dr. Fergus, of Marlborough, which was alkaline? 
and contained crystals of triple phosphate. It came from a patient, 
18 years old, who was feverish with gastric and biliary disturbance. 
The urine was high coloured, 8p gr. 1*033, and became nearly solid 
upon the addition of an equal bulk of nitric acid, from the formation 
of crystals of nitrate of urea. (April, 1862.) 

207. Clinical Observations.— There are some peculiar and not 
very common cases in which the urine contains this excess of urea; 
and at the same time more than the healthy amount is excreted in 
twenty-four hours. The patient is weak, and grows thin, in spite of 
taking a considerable quantity of the most nutritious food. He feels 
languid, and indisposed to take active exercise. In some cases, 
digestion is impaired ; in others, the patient eats well, experiences 
no pain or uneasiness after food, and perhaps has a good appetite. 
Sometimes there is lumbar pain. It would seem that much of the 
nutrient material in the blood, instead of being applied to the 
nutrition of the tissues, becomes rapidly converted into urea, and 
is excreted. The waste of the tissues is not properly repaired, and 



DEFICIENCY OF UREA. 157 

the patient gets very thin. To refer these symptoms to the existence 
of a particular diathesis, appears to me no explanation of the nature 
of the case. The pathology of these remarkable cases has not yet 
been satisfactorily investigated. Mineral acids, rest, shower-batiis, 
and good air, often do good ; but some of these patients are not in 
the least benefited by remedies, and they continue for years very 
thin, passing large quantities of highly concentrdted urine, while the 
appetite remains good, and they digest a considerable quantity of 
nitrogenous foods. In one of these cases, which had resisted the 
usual plans of treatment, benefit was derived from the use of 
pepsine,* with diminished quantity of meat, and a larger amount of 
farinaceous food. The condition often lasts for some years. 

208. Defloienoy of TJrea.— In chronic disease of the kidney, 
the urine is of very low specific gravity, and but a very small pro- 
portion of urea is excreted in the twenty-four hours. This arises 
from the alteration in the gland-structure, and the amount of urea 
separated may be regarded as a rough indication of the extent of 
the organ involved. In some cases, the morbid condition afiects the 
whole structure; but in others the greater part of the kidney 
remains healthy. In the latter case, a fair amount of urea will be 
excreted ; and, although the urine contains albumen, the case may 
be looked upon as a hopeful one. Sometimes the quantity of urea 
excreted is very small. A lady sufiering from an ovarian tumour 
only excreted 75 grains of urea in 200 fluidrachms of pale faintly 
alkaline urine in the course of twenty-four hours. (T^udichum). 
In a case of cancer of the uterus, under the care of Dr. Farre, only a 
few drachms of fluid were passed from the bladder during a week ; 
and this contained a small quantity of solid matter, in which no 
urea was detected. 

In certain cases, urea almost entirely disappears from the urine, 
and is replaced by leucine and tyrosine. Frerichs mentions a case 
of acute yellow atrophy of the liver, in which only a trace of urea 
could be detected, while a very large quantity of leucine and tyro- 
sine crystallised from the concentrated urine. C* Klinik der Leber- 
krankheiten,'* Erster band. Seite 221.) In low forms of typhoid 

* The pepsine I always use is that prepared, according to a plan I proposed, bj 
Messrs. Bullock & Reynolds, Hanover Street, W. ("* Archives of Mtdieine,** Vol. L, 
pp. 269, 316.) See also the paragraphs on the treatment of Diabetes. 



158 COLOURING MATTEB 

fever, the urine also firequently yields leucine and tyrosine in con- 
siderable quantity. 

In a case of chronic yellow wasting, which came under my own 
notice (F. C, VoL vi., p. 37), the liver was of a yellow colour, and 
weighed li lb. The patient was a young woman, age 26. Jaundice 
had existed for six weeks, but urgent symptoms— delirium and 
coma — ^had only supervened a few days before death. Leucine was 
obtained from the urine by evaporation, but only in small quantity. 

209. OoloTirixiff Matter. — The variation of colour of the urine 
in disease is a matter of great interest ; and, although the causes of 
the change, and the exact nature of the substances which give rise to 
the peculiar tints often observed, are not yet understood, still there are 
many valuable observations connected with this subject, some of which 
I propose to refer to in this place. The colour of urine depending upon 
blood corpuscles being suspended in it will be discussed under the 
head of urinary deposits; and now I shall only refer to colouring 
matters formed in the body and excreted in solution in the urine. 
It should be observed, that pyrola, sumach, and some other sub- 
stances, alter the colour of the urine. Dr. Hughes mentions cases 
of dark pigment occurring in the urine of patients taking iodine. 
These cases, however, are of course not dependent upon morbid 
changes in the organism. 

The principal substance to which the colour of urine is due is 
probably derived from the blood corpuscles, which are continually 
undergoing disintegration. This colouring matter becomes altered 
under different conditions. Much of it is converted into a colouring 
matter which is separated in the urine, and termed urasmatine 
(uraphsBin, hsemaphine), which is soluble in ether, and, according 
to the researches of Dr. Harley, is a resinous body, agreeing in some 
of its characters with the biliary resins. 

It is impossible to estimate directly the quantity of the colouring 
matter present; but Professor Vogel calculates the proportion by 
ascertaining how much water may be added to the urine to produce 
a particular tint, which is arbitrarily fixed as the unit of comparison. 
The quantity of this substance affords an indication of the activity 
of the disintegration of the blood-corpuscles. In typhoid fever, and 
many other conditions, this disintegration takes place to such an 
extent as to produce an anaemic condition. In many acute diseases. 



IN THE URINE. 159 

a very large amount of colouring matter occurs in the urine. 
Urea is not unfrequently present in excess in pneumonia, typhus 
fever, peritonitis, acute rheumatism, etc. The formation of the 
urine-pigment is intimately connected with the action of the liver; 
and, as is well known in diseases of this organ, the urine is 
frequently very high coloured. Of course, I am speaking of colour 
independent of the colouring matter of the bile. The deep colour of 
the urine in diseases of the liver has been often remarked by physi- 
cians practising in India; and quite recently my friend Dr. Payne 
has made some interesting observations on this point, which will be 
found in the ^^ Indian Annals of Medical Science^'* (Calcutta, 
Sept. 4th, 1858). In order to detect the colouring matter, Dr. 
Payne boils the urine, and then adds a drop of nitric add. Various 
shades of colour are produced, but at last the mixture becomes of a 
ruby red. Deficiency of colouring matter occurs in many cases of 
anaemia. Sometimes the urine is as pale as water. 

Heller's observations upon the colouring matter have been 
alluded to (§ 112). This observer found more uroxanthine "(which 
may be decomposed into indigo blue or uroglaucine, and indigo red 
or urrhodine) in the urine of persons suffering from diseases of the 
serous membranes, of the kidneys, and of the spinal marrow, than in 
the healthy secretion. Schunk, who first separated indigo blue and 
indigo red, and showed their identity with Heller's uroglaucine and 
urrhodine, found as much uroxanthine or indican in healthy as in 
morbid specimens of urine ; and he detected it in the urine of 
thirty-nine persons out of forty. The Quantity of this colouring 
matter is exceedingly small. Schunk, by working on the urine of 
two persons for several weeks, only obtained one grain of indigo 
blue. 

My friend Dr. Bade, of Norwich, sent me a specimen of urine 
containing a deposit of uroglaucine obtained from a man eighty- 
three years of age. {^^ Archives of Medicine" vol. i., p. 311.) Some of 
these crystals are represented in Plate XII., Fig. 64 ; and in Fig. 63 
are shown some crystals of indigo, a, crystals obtained by sublima- 
tion ; b, larger crystals of the same ; c, small crystals of indigo in 
fluid. Fig. 64 contains numerous crystals of uroglaucine from the 
urine, a, small collections of a pale blue colour, like Prussian blue ; 
&, a darker mass, formed of small spherical masses; c, crystals of 
uroglaucine, of a deep purple or violet colour. 



160 TESTS FOR UROXANTHINE. 

810. Tests for TJpoxanthine.— When sulphuric axjid is added 
to urine containing much uroxanthine, a dark blue colour is pro- 
duced. The mode of employing this test recommended by Dr. 
Carter, who has made some important investigations on this subject 
(^Edinburgh Medical JoumcUy' Aug. 1859), is as follows :— Urine 
is poured into an ordinary test-tube, to the depth of half an inch ; 
one-third of its volume of sulphuric acid, specific gravity 1,830, is 
then allowed to subside to the lower part by letting it fell gradually 
down the side of the tube ; the acid and urine should then be mixed 
well together. The colour produced varies from a faint pink or lilac 
to a deep indigo blue colour. 

Is uroxanthine to be considered an ingredient of normal urine ? 
As Schunk found this substance in the urine of thirty-nine healthy 
persons out of forty, and Dr. Carter recently detected it in the urine 
6f three hundred persons (some suffering from disease, others 
healthy), we may, I think, regard it as a constituent of healthy 
urine. Dr. Carter has detected it in the blood of several patients — 
in fact, in every case in which he sought for it It was also found 
in the blood of the ox. 

Process, The serum was poured off, and a strong solution of 
diacetate of lead added to it as long as a precipitate was produced. 
The mixture was then thrown upon a linen filter, and the filtrate 
was brought to the boiling-point as rapidly as possible in a small 
fiask, in order to coagulate the albumen that had not been 
precipitated by the lead salt. The solution was then filtered through 
paper into a vessel placed in cold water; and, when the liquid was 
cold, a slight excess of caustic ammonia was added. The deposit 
thus produced, when collected and slightly washed with water, was 
of a faint yellowish buff colour. The moist precipitate, upon being 
treated with excess of concentrated sulphuric acid, developed a 
distinct red colour, owing to the formation of indigo red. The 
colour was taken up by ether, after the acid had been neutralised by 
ammonia. The oxide of lead precipitate, from an 9unce and a half 
of blood-serum from a man, forty-three years of age, suffering from 
acute pleurisy, struck with the acid a distinct lavender colour, which 
in half an hour passed into a deep red purple. (" On Indican in the 
Blood and UrinCy^ by J. A. Carter, M.D. ; '^Edinburgh Medical 
Joumaly* August, 1859.) 



URORGLAUClNlL— INDIGO. 



Plate XII. 



Fig. 61. 
® of 



Fig. 62. 



a^» 



e 




§ 173 



§ 166 



Fig. 63. 




Fig. 64. 

2¥* 






^ 



^ 



^'J^ 



§ 209 



Fig. 65. 




^^ 



§ 202 



To Jouce •^ao*^-^- 



BLACK PIGMENT. 161 

211. OolonrinfiT Uatter of the Blood.— The colouring matter of 
the blood-corpuscles may be present in urine without any corpuscles. 
In many cases, owing to the rapid disintegration of blood-corpuscles, 
the serum is highly coloured, and the dissolved colouring matter is 
excreted by the kidneys. Blood may escape from the vessels into the 
tubes of the kidney, the corpuscles may gradually become disin- 
tegrated, and the colouring matter be dissolved; hcematoghhuline 
coagulates at a temperature of about 200*, while alhumen is pre- 
cipitated at a temperature a little above 140°. In this manner these 
substances may be distinguished. 

There can be little doubt that both the colouring matter of the 
bile and of the urine are derived from that of the blood-corpuscles. 
The precise manner in which the change is accomplished has not yet 
been demonstrated, but it is not improbable that careful observations 
upon the urine in disease would lead to a solution of this question. 
That bile-acids and their salts were powerful solvents of blood- 
corpuscles, was long ago proved by Hiihnefield, Plattner, and Simon; 
and it has lately been shown by Kuhne that, by the action of the 
colourless biliary acids or their salts upon the blood-corpuscles, bile- 
colouring matter is produced. The bile-acids themselves are not 
converted into the colouring matter, as Frerichs held; for they pass 
through the system unchanged. Now, in certain cases where these 
processes are deranged, it is very probable that the blood-corpuscles 
are disintegrated in abnormal quantity, and rapidly converted into 
pigment, which escapes in the urine. The complicated mutual 
reactions which would ensue when varying proportions of biliary 
acids, hsBmatine, and oxygen, are presented to each other in the 
living blood, would fiilly account for the different characters and 
tints which the colouring matters in urine assume in various cases. 
Professor Vogel alludes to a case in which the colour of the urine 
became very dark after the inhalation of arseniuretted hydrogen. 
Some experiments were made upon a dog, and it was found that the 
dark colour was due to the disintegration of Wood -corpuscles. 
Albumen was present, but no blood-corpuscles could be detected. 
A similar disintegration of blood-corpuscles seems to take place in 
typhoid fever, and in several other diseases. 

212. Black Piflrment.— Dr. Marcet describes a black pigment 
which was present in the urine of a child. After the addition of an 



162 URIC ACID AND URATES. 

acid, some black flocculi were deposited. Professor Dulk gives a case 
in which a black deposit was separated from the urine by filtration. 
Other examples are recorded by Dr. Hughes. In three of these cases, 
creasote had been taken internally; and in two, tar had been applied 
externally. In one case, a dense black precipitate was thrown down 
by heat and nitric acid, which was examined by Dr. Odling, who 
found that, by exposure, it became converted into indigo blue. He 
draws attention to the close alliance between indigo and the creasote 
series of compounds, and suggests that, in the above cases, it was 
derived from the tar or creasote. (Quoted in Dr. Golding Bird's 
work, fifth edition, edited by Dr. Birkett.) 

213. TTrio Aoid and TTrates are present in certain proportion in 
healthy urine, but in disease a large increase is very frequently 
observed. These substances form urinary deposits, either from 
existing in too large a proportion to be dissolved in the urine when 
cold, or, as is probably the case in the majority of instances, from 
the development of an acid in the urine, which causes them to be 
precipitated from their solutions. The microscopical characters of 
these bodies will be considered under the head of urinary deposits. 
In many acute febrile diseases, the proportion of uric acid is in- 
creased, and the period of resolution of the inflammation is marked 
by diminished frequency of the pulse and respiration, by a fall in 
the temperature, by free perspiration, and by a very abundant 
deposit of urates. In health, from 6 to 8 grains of uric acid are 
excreted in twenty-four hours ; but, in some acute diseases, the pro- 
portion may amount to twenty grains. In a case of fever. Dr. 
Parkes found that 17*28 grains of uric acid were excreted in twenty- 
four hours. Dr. Sansom has estimated the quantity of uric acid in 
1,000 grains of the morning urine in health and several cases of 
disease. The results are as follows : — 

Grains. 
Health -250 

Acute Gout -830 

Acute Rheumatism '802 

Heart Disease 711 

Erysipelas '679 

Phosphatic Urine '140 

Chronic Gout '120 

Excessive Debility '078 



TREATMENT. 163 

Urate of soda is very readily caused to deposit crystals of uric 
acid. If the amorphous deposit be merely dissolved by warming 
the urine, the urate often becomes decomposed ; and, as the solution 
cools, crystals of uric acid are deposited. In some cases, the quan- 
tity of uric acid held in solution is so great that, upon the addition 
of a drop of nitric acid to the urine, an abundant amorphous pre- 
cipitate, exactly resembling albumen, is formed. Such a precipitate 
has many times been mistaken for albumen (see ^^ Albuminous 
Urine "), and, even if examined under the microscope immediately 
after it is formed, its nature cannot be made out; but if it be 
allowed to stand for some time, the amorphous particles gradually 
increase in size, and assume the well-known crystalline form of uric 
acid. The instances in which I have met with urine exhibiting 
these characters have almost all been cases of liver-disease* 
Although the reaction is acid, no precipitate takes place upon the 
application of heat, which at once distinguishes urine of this 
character from albuminous urine. 

The presence of an increased quantity of uric acid in the urine 
shows that more of this substance or its salts is formed in the blood 
than in health. It would appear that, in consequence of certain 
conditions, a large proportion of the uric acid resulting from the 
disintegration of albuminous substances is not ftirther oxidised and 
converted inte urea, but combines with ammonia, soda, or lime, 
forming urates of these bases. 

In gout, the presence of uric acid in the blood has been shown 
to be constant by Dr. Garrod, who considers that in this condition 
" the kidneys lose, to some extent, their power of excreting uric 
acid,'' although they eliminate urea as in health. (" The Nature 
and Treatment ofOout!'' p. 167.) During the attack there is less in 
the urine than in health ; but, after it is over, a large quantity of 
uric acid and urates are often carried off frx)m the system in the 
urine. 

214. Treatment of Oases in which the TTrio Acid is in 
Excess. — In cases characterised by a tendency te the formation of 
much uric acid, the principal objects to be attained by treatment 
are, te favour the further oxidation of the uric acid formed, and to 
promote its solution and elimination from the blood as rapidly as 
possible. Good air and moderate exercise, with attention to the 



164: TREATMENT. 

action of the skin, will fulfil the first object ; and the solution and 
elimination of the urates will be encouraged by giving alkalies in 
solution in a considerable quantity of water. 

The satisfactory change which, in chronic gouty and rheumatic 
cases frequently ensues firom following some of the much vaunted 
'* systems/' or going through a course of bathing in Germany or else- 
where, obviously arises from the increased action of the skin, and 
the improvement of the health generally, efiected by the exercise, 
good air, simple diet, and temperance, wisely enforced in the estab- 
lishments. If patients could be induced to retire to a pleasant part 
of the country, where they could take moderate exercise and be free 
from mental anxiety, meet with agreeable society, live regularly, 
take small doses of alkalies, and soak themselves for an hour or two 
a day in warm water in which some carbonate of soda had been 
dissolved, they would receive as great benefit as by travelling 
hundreds of miles away, and at much less trouble and expense. I 
am convinced that there are many patients who would prefer to 
carry out such a simple plan, rather than submit themselves to all 
the useless routine and absurd formalities involved in many of the 
professed universal systems, such as homoBopathy, hydropathy, etc., 
which cannot but be extremely offensive to their common sense, — 
while they are claimed as converts and supporters of doctrines which 
they do not really believe in. There are many who, for the sake of 
the advantage they derive from the regular system of living, air, 
exercise, etc., express no disbelief in doctrines and propositions 
which they probably feel to be absurd, and which a little reflection 
must prove to be false. 

In all such cases, the nature of the derangement of the physio- 
logical processes should be carefully considered before any plan of 
treatment is adopted. We must ascertain in what points the 
condition differs from a healthy state, and then consider how the 
deranged actions may be restored. It is obviously quite useless to 
attempt to relieve the patient by giving drugs, without enforcing 
attention to all the circumstances which are likely to improve the 
health. Neither will it be wise to attempt to treat the case as if the 
presence of the uric acid deposit were the most important symptom, 
for the reasons I referred to when considering the subject of 
diathesis. 



EXTRACTIVE MATTERS. 165 

215. Hippurio Acid, as before mentioned, never forms a deposit.* 
In diabetic urine, it is often found in large quantity, and seems to 
take the place of uric acid. It is also found in large quantity in the 
add urine of fever patients (Lehmann). This fact is of great interest, 
when considered in connexion with the sugar-forming function of the 
liver, and the absence of hippuric acid in the organism in certain 
cases of liver-disease. Ktihne has shown that no hippuric acid can 
be detected in the urine in cases of jaundice; and benzoic acid, which 
in health is converted into hippuric acid, escapes unchanged into the 
urine. There can, therefore, be little doubt that this substance is 
formed in the liver, whether by the action of glycin or glycocholic 
acid on benzoic acid, or some other substances, has not been 
determined. When febrile urine is evaporated over the water-bath, 
crystals of benzoic acid often form on the sides of the basin. This 
arises from decomposition of the hippuric acid. 

To Lehmann's statement, that hippuric acid takes the place of uric 
acid in diabetic urine, there are many exceptions. I have found a con- 
siderable proportion of uric acid in the urine of many diabetic patients, 
and in several there was an abundant deposit of uric acid crystals. 

216. Extractive Matters. — The extractive matters present in 
healthy urine have been previously described; and I have mentioned 
that Dr. G. 0. Kees has discovered in the urine, in certain cases, an 
extractive matter which has drained away from the blood, and which 
is distinguished by producing an abundant precipitate with tincture 
of galls, ^ow, although in many cases albumen exists in the same 
specimens of urine, this blood-extractive sometimes escapes without 
albumen; and thus the exhaustion and emaciation, in some obscure 
cases in which there is no hasmorrhage or escape of albumen, are 
accounted for. The method of testing urine supposed to contain this 
extractive matter has been described (§ 144). The conclusions at 
which Dr. Kees has arrived are as follows: — 

1. That whenever albumen was present in quantity in the urine, 
it was always accompanied by the extractives of the blood in large 
proportion. 

2. That the cases in which the extractives of the blood were in the 
urine in large proportion, were generally those marked by debility. 

* Dr. William Budd in certain specimens of urine in cases of gout has observed a 
floccnlent precipitate, which was found to consist of benzoic acid, doubtless resulting 
from the decomposition of hippuric acid. 



166 mCBEASE OF ORGANIC MATTERS. 

3. That cases of anasarca with disease of the heart, and uncon- 
nected with albuminuria, also showed the extractives of the blood to 
be excreted by the urine in quantity. 

4. That cases of chlorotic ansemia and hysteria give copious 
precipitates. 

5. That when, in albuminuria, the albumen became deficient in 
the urine, which we know often happens in advanced cases, the 
blood-extractives also decrease in quantity. 

6. That, in cases of ansemia, the proportion of blood-extractives 
observed in the urine diminished as the cure was proceeding, under 
the use of ferruginous tonics. (Lettsomian Lectures, ^^ Medical 
QazetUi' 1861.) 

In many cases where the urine contains an abnormal quantity of 
water, the proportion of blood-extractives is unusually great. In 
cases of kidney-disease, the relative proportion of extractive matter 
to the urea is very much greater than in healthy urine. It would 
seem that extractives merely filtered from the blood in certain cases, 
and that these substances might escape into the urine when the 
structure of the kidney was impaired; but that, for the separation 
of the urea, a healthy condition of the secreting structure is 
necessary. 

The extractive matters are not capable of being converted, by 
further oxidation, into urea, carbonic acid, or ammonia; and must, 
therefore, be regarded as excrementitious substances. Scherer 
(" Wurzburg Verhandl,'' B iii., Heft II., p. 180.) found that the urea, 
salts, &c., in the urine of a madman who took no food, were very 
much diminished; while the extractive matters, although less than 
in healthy urine, were not diminished in nearly the same proportion 
as the other urinary constituents. 

We know nothing of the circumstances under which the extractive 
matters may be formed in greater quantity than in health, nor the 
effects which would result from their accumulation in the blood. 

217. General Bemarks on the Increase of the Orgranic 
Oonstitaents of TTrine.— The circumstances under which these con- 
stituents are excreted in increased quantity have been already 
considered, and I propose now to direct attention to a few analyses 
of the urine in cases of disease in which this character is observed. 
In almost all forms of fever, in internal inflammations, in acute 



UBINE m SKIN DISEASE. 



167 



rheumatism, in many skin-diseases, and in all conditions in which 
there is increased action of the muscular system, the solids are con- 
siderably above the healthy standard; but the various constituents do 
not suffer augmentation in an equal degree. In the conditions just 
referred to, the increase principally affects the organic matters. 
Sometimes all the ordinary constituents of the urine are excreted in 
increased proportion. Dr. Lehmann {'^Archiv des Vereins fUr gem. 
Arb. zur Forderung der wissench." Hdlhunde, JErster Band, Seite 
521), has shown that immersion in the sitzbath, at a temperature of 
48° to 60° Fahr., for a quarter of an hour, causes an increase in the 
quantity of urine, not only of the^ater, but also of the solid matter. 
The uric acid, the urea, and the fixed salts, were considerably 
increased. These results were obtained by estimating the constituents 
in urine passed during six hours on certain mornings when a bath 
was taken, and upon others when the observer did not bathe. 

The mean of eight analyses of the urine passed during six hours 
is as follows: — 





Iiomiiiffs on 

wUch the bath 

was taken. 


Momhigs on 
which the bath 
was not taken. 


Water 


. 443-454 grams. 


258-456 grama 


Solids 


. 19-403 


»» 


14-459 „ 


Urea .... 


. 10-396 


» 


7-080 „ 


Uric Acids 


0-130 


w 


0-108 „ 


Fixed Salts . 


6-982 


w 


4-821 „ 


Volatile Salts and Extractive 


1-89 


59 


2-45 „ 


Chloride of Sodium . 


. . 5-814 


n 


4-319 „ 



218. Urine in Skin Diseases.— In the following analyses of 
urine in cases of skin disease, the solid matter is increased ; and it 
will be noticed that the proportion of fixed salts to the organic 
matters is greater than in health. In No. 4, the quantity of the 
extractive matter exceeds that of the urea. 

Analysis 3. — ^Urine from a case of eczema, with crusts over the 
whole body : specific gravity, 1,025. 

Analysis 4. — From the same patient on tlie following day. 

Analysis 6. — From a case of eczema, in a boy, aged 18 : specific 
gravity, 1,033 ; acid, pale colour. Contains much uric acid. 

Analysis 6. — From a case of ichthyosis, in a girl, aged 16 : acid ; 
specific gravity, 1,032. 



168 UBINE IK CHOREA. 

210. TTxine in Ohorea.— In the second series of analyses of the 
urine in chorea, the principal points to be noticed are the large 
amount of solid matter, the increase being caused principally by the 
organic matters. In Analysis 11, the proportion of sulphates is 
seen to be increased. This increase of sulphuric acid is always 
observed in cases where the urea is increased. 

Analysis 7. — ^From a girl, aged 10, recovering — after having been 
ill for several weeks. The urine contained a great number of 
Cayenne pepper crystals of uric acid. 

Analysis 8. — From a girl, aged 12 : specific gravity, 1,033 ; no 
albumen; much deposit of urates. 

Analysis 9. — From a girl, aged 14: specific gravity, 1,035; 
add ; turbid, £rom the presence of urates. Uric acid deposited in 
the urine = '46 per 1,000 parts. 

Analysis 10. — From a girl: specific gravity, 1,030; acid; pale 
in colour. 

Analysis 11. — From a boy, about 10 years of age. 

Analysis 12. — ^From a boy, aged 14: acid; specific gravity, 
1,034-2. 



169 



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171 



CHAPTER X. 



Urine in Disease — Excess or Dejidency of the Inorganic Con' 
stituents present in Health — Urine in Pneumonia — Chloride 
of Sodium: its Diminution in Acute Inflammation — Urine 
in Elephantiasis Grcecorum — Excess of Sulphates — Increase 
in Cases of Chorea^ Rheumatic Fever, Sfc. — Influence of 
Remedies — Excess and Deficiency of Alkaline Phosphates—^ 
Increased Secretion of Alkaline Phosphates in Inflammation 
of the Brain (f) — Dr. Bence Jonei Observations — Analyses — 
The Author^s Observations on the Phosphates — Paralysis of 
the Insane — Acute Mania with Paroxysms — Chronic Inflam- 
mation of the Brain — Epilepsy — Delirium Tremens and 
Puerperal Mania — Phosphates in Healthy Urine — Variation 
in the Quantity — Earthy Phosphates— ^Increase in the Urine 
of Cases of Mollities Ossium — Analyses — Excess of as 
distinguished from mere Deposits of Earthy Phosphates, 

Excess or Deficiency of the Inoboanio Constituents. 

In disease, the inorganic salts vary greatly in quantity. Some- 
times the saline constituents are very deficient. In cases of diabetes, 
sometimes, there are only traces of fixed salts. This deficiency may 
depend upon the nature of the food, or it may be due to ih^ formation 
of a diminished proportion of some of the salts in the organism. The 
sulphates, and the phosphates in part, being formed in the body, will 
vary under many circumstances. 

In some conditions of the system, when much disintegration of 
tissue or red blood corpuscles takes place, a greater quantity of 
sulphur and phosphorus is oxidised, and the corresponding acids are 
formed in unusually large proportion, and excreted in the urine. 

I 3 



172 X7BINE IN PNEUMONIA. 

In certain inflammatory conditions of the system, it would appear 
that the chloride of sodium, being required in considerable quantity 
at the seat of the inflammatory change, is prevented from passing off 
^m the system in the urine. In disease of the kidney, it is 
important to notice if the proportion of the saline constituents to the 
oiganic matter is very much increased. In some states of renal 
disease, in which the secreting structure of the kidney is so much 
impaired that the separation of urea and organic matter is interfered 
with, a proportion of saline matter, considerably larger than that 
which is present in the urine in health, escapes. 

220. TTxine in Pneumonia. Chloride of Sodium. — The fluc- 
tuations observed in the quantity of common salt excreted in the 
urine are very great even in health. The circumstances which affect 
the proportion of chloride of sodium are very numerous, and these 
are greatly increased in disease. It was found by Kedtenbacher, 
many years since, that in pneumonia the quantity of chloride in the 
urine gradually decreased as the inflammation advanced; and that 
in many instances, when the lung became hepatised, not a trace 
could be detected in the urine. Some years ago, I determined 
quantitatively the amount of chloride in the urine from day to day, 
in several cases of acute pneumonia. (" Med. Chir, Trans.,'' Vol. 
XXXV.) The following case illustrates very well the changes which 
occur in the urine in this affection. 

The patient was a plasterer, aged 24, and was under the care of 
Dr. Budd, in King's College Hospital. On the third day of the 
disease, there was dulness two inches below the left mamma in front, 
and behind over the space below the spine of the scapula. Bronchial 
breathing and bronchophony were audible over the lower angle of 
the scapula. Expectoration viscid, frothy, and slightly rusty. Pulse 
144, small and weak. Respiration 52. 

On the fourth day of the disease, bronchial breathing and 
bronchophony were more distinct. Pulse 116. Respirations 28. 
He was treated with small doses of antimonial wine, and was placed 
upon milk diet and beef-tea. Turpentine stupes were applied to the 
chest. He progressed favourably; was convalescent within three 
weeks after the commencement of the attack, and was discharged well 
in little more than four weeks. 



ABSENCE OF CHLORIDE. 



173 



Analysis 13. Fourth day of the disease. Urine high coloured; 
acid; specific gravity, 1,017; contained a little albumen. 

Analysis 14. Fifth day. Acid; specific gravity, 1,013; natural 
colour. 

Analysis 15. Sixth day. Acid; specific gravity, 1,016; pale; 
still contained a trace of albumen. 

Analysis 16. Tenth day. Acid; specific gravity, 1,022; no 
albumen. 

Analysis 17. Twenty-second day. Acid; specific gravity, 1,016; 
pale; no albumen. 

Analyses. 



Water . 


. 956-60 




957-40 


954-00 


^ 


Solid Matter 


. 43-40 


100-00 


42-60 


46-00 


100-00 


Organic Matter 


. 40-28 


92-82 




44-64 


97-05 


Fixed Salts . 


3-12 


7-18 




1-36 


2-95 


Chloride of Sodium 







traces 











16 


17 


Water 




955-00 


^ 


968-40 




Solid Matter 




. 4500 


100-00 


31-60 


100-00 


Organic Matter . 




42-12 


93-64 


23-26 


73-61 


Fixed Salts 




2-88 


6-4 


8-34 


26-39 


Chloride of Sodium 









4-56 


14-43 



The decrease of the fixed salts generally, during the stage of 
hepatisation is remarkable. The last analysis of the urine, when the 
patient was well, shows the healthy proportion. In Vol. XXXV. of 
the " Medico Ghirurgical Transactions^^ will be found several other 
cases showing similar results. In some of the cases, it was shown 
that, although there was not a trace of chloride in the urine, and the 
blood contained less than its normal proportion, the sputa were very 
rich in chloride of sodium. In one case, the proportion amounted to 
upwards of 18 grains in 100 of the solid matter of the sputum. In 
a fatal case, much chloride was found in the products effused into 
the air-cells of the lung. In most exudations, and in growing tissues, 
there is a considerable amount of chloride of sodium. In acute 
inflammations generally, the proportion of chloride in the urine 
gradually diminishes until the disease is at its height. When resolu- 



174 URINE IN PNEUMONIA. 

tion occurs, the chloride reappears, and gradually increases as con- 
valescence advances, until it attains its normal standard. The 
amount of chloride in the urine is much influenced hy the nature of 
the food, and by the quantity of fluid taken, as I remarked when 
treating of the chloride in healthy urine ; but the results above 
described cannot be explained in this manner ; for, although patients 
take less food when they are ill, and therefore less salt, the same 
results are observed if salt be given to them. Moreover, the dis- 
appearance is gradual, and the reappearance is marked by a change 
in the symptoms of the disease, although the food has remained the 
same during the whole period of the illness. 

There can be little doubt that, in these cases, the chloride is 
gradually separated from the blood in undue proportion at the point 
where the inflammatory changes are taking place ; and that, instead 
of passing through the organism as it does in health, it accumulates 
at this point until a certain stage of the morbid process is passed, 
when the cells, which have been growing and multiplying so feist, die 
and become disint^rated and dissolved, the products thus formed 
with the chloride of sodium being reabsorbed into the blood, and 
afterwards altered and at length excreted by the ordinary channels. 
The precise office which the salt plays in these processes is not under- 
stood ; but certainly, in all the specimens of inflammatory lymph 
that I have examined, I have always found common salt present in 
large quantity. In many cases of bronchitis, acute rheumatism, 
pleurisy, in some cases of skin-disease, and in some other instances 
in which its absence would appear to be merely an accidental circum- 
stance, no salt can be detected in the urine. We cannot, therefore, 
regard this diminished proportion or absence of chloride in the urine 
as a point of any value in the diagnosis of pneumonia, although it 
must be looked upon as a fact of great interest with reference to the 
morbid changes which are taking place at the time. The conclu- 
sions to which I arrived, after examining the urine, blood, sputum, 
and inflammatory products, in several cases of pneumonia, are as 
follows : — 

1. That in pneumonia there is a total absence of chloride of 
sodium from the urine at or about the period of hepatisation of 
the lung. 

2. That, soon after resolution of the inflammation, the chloride is 
again present in the urine, and often in considerable quantity. 



DIURETICS AND SUDORIFICS. 175 

3. That, at this period (resolution), the serum of the blood is 
found to contain a greater amount of chloride than in health. 

4. That the presence of chloride of sodium in the urine may be 
taken as evidence of the existence of a greater quantity of the salt 
in the blood than is required for the wants of the system generally, 
or, at least, of an amount sufficient for that purpose ; and that the 
absence of the salt from the urine indicates that the circulating fluid 
contains less than the normal quantity. 

6. That the sputa in pneumonia contain a greater quantity of 
fixed chloride than healthy pulmonary mucus, if there be not much 
less than a normal amount in the blood, although there be a com- 
plete absence of the salt from the urine. In all cases, however, there 
is found in the sputa a quantity many times greater than exists in 
an equal amount of blood at the same period of the disease. The 
absolute amount present is subject to variation at different periods 
of the disease, and in different cases. 

6. That, in one case which was fatal, the proportion of chloride 
present in the sputum underwent a decrease, while the amount of 
solid matter, and especially the extractive matters, increased in 
quantity. At the same time, the sputum became acid ; and in the 
matters expectorated within the last few hours of the patient's life, 
a large quantity of grape-sugar was found ; but, in that obtained on 
the day previous to his death, none could be detected. 

7. The absence of chloride of sodium from the urine during the 
stage of hepatisation seems to depend upon a determination of this 
salt to the inflamed lung ; and, when resolution occurs, this force of 
attraction ceases, and whatever salt has been retained in the lung is 
reabsorbed, and appears in the urine as usual. 

221. On the eifeots of Diuretics and Sudorlflos in certain 
Acute Inflammations.— The increased secretion of urine, the profuse 
sweating, often accompanied with increased action of the bowels, 
which mark the occurrence of resolution of the inflammation or the 
death of the cells entering largely into the formation of the lymph, 
are undoubtedly encouraged by giving acetates, citrates, carbonates, 
and some other salts. Indeed, it is almost certain that, in many 
cases, these critical discharges take place at an earlier period in 
consequence of the action of the remedies. If profuse sweating and 
diuresis can be brought about quickly, it is even a question if the 



176 URINE IN ELEPHANTIASIS GRiECORUH. 

disease may not sometimes be cat short How can the action of this 
class of remedies be explained 1 There can be no doubt that, by an 
increased action of the excreting organs, many sabstances which 
would have been absorbed by the growing cells are eliminated, but 
it is probable that the salts given in these cases act favourably in 
another and not less important manner. Chloride of sodium seems 
absolutely necessary to the growth of the inflammatory products, 
while the salts given as medicines exert an unfavourable influence, 
and, the latter being in the blood in considerable quantity, would 
be poured out at the seat of inflanmiation, and take the place of the 
chloride of sodium, driving out the latter. Under these conditions 
the cells soon cease to multiply, die, and undergo disintegration, the 
products being absorbed and afterwards excreted. 

222. Urine in Elephantiaaia Gxsdooram. — Analysis 18 repre- 
sents the composition of the urine in an extreme case of elephantiasis 
Gracorum, occurring in a boy about twelve years of age, who was in 
the hospital some years ago, under Dr. Todd. The emaciation was 
extreme, and there were a great number of large ulcerated tubercles 
all over the body, which discharged freely. The absence of the 
chloride may, perhaps, be accounted for by the presence of exuda- 
tion and cell development at the bases of these numerous ulcers. 
The urine was acid ; specific gravity 1,020. 

Analysis 18. 

Water. .... 960*0 

Solid mat ..r .... 40*0 100*00 

Fixed »^^'8 .... -51 11 -27 

The ash ^ ^%ted of sulphates and phosphates, with a mere trace 
of chloride. 

Analysis 19. 

Another specimen about two months after the last. Specific 
gravity, 1,014; acid. 



Water 


965-1 




Solid matter . 


34-9 


10000 


Urea 


13-97 


40-02 


Extractives 


16-06 


46-01 


Uric acid . 


•31 


•88 



EXCESS OF SULPHATES. 



177 



Alkaline salts 


4-07 11-66 


Earthy salts 


•49 1-40 


Sulphuric acid 


•422 1-20 


Phosphoric acid 


1-389 3-98 


Chloride of sodium 


not a trace. 



228. Urine in Hysterical Coma. — It is difficult to account for 
the absence of the chloride in the following analysis. The urine was 
obtained from a woman, aged 31, suffering from hysterical coma. 
About eleven ounces were drawn off" by a catheter. The patient was 
quiet; skin cool ; tongue covered with a thick white fur; pulse 136; 
respiration 18 ; sensation very much impaired. The patient did not 
notice a very severe pinch with the nails. 





Analysis 20. 






Water 


, , 


921-41 




Solid matter . 


. *• 


78-59 


100-00 


Uric acid . 


, , 


•57 


-72 


Urea extractives, &c. 


, 


67-70 


86-15 


Fixed salts 


, 


10-32 


1313 



The salts contained sulphates and phosphates, but not a trace of 
chloride was present. 

224. Excess of Sulphates: Action of Liquor PotassaB. — 
I have already observed that the proportion of sulphates usually 
varies according to the urea; and it follows that, in diseases charac- 
terised by a considerable disintegration of muscular tissue, we shall 
find an unusual amount of sulphate in the urine. In chorea, the 
increase of the sulphates and urea is often very considerable ; but 
there are conditions in which the increase of the sulphates does not 
appear to be associated with the formation of urea to a correspond- 
ingly large amount. An increase in the quantity of sulphate in the 
urine, in cases of rheumatic fever, is noticed in some of Dr. Bence 
Jones' analyses. In one case, on the fifth day, the urine had a spe- 
cific gravity of 1,026, and yielded 11-89 grains of sulphate of baryta. 

Dr. Farkes has shown, by some very careful experiments on four 
cases, that in rheumatic fever the sulphuric acid is greatly increased. 
In one case, 52^ grains of sulphuric acid and 5^ grains of unoxidised 
sulphur were excreted in twenty-four hours. The urea was not 
increased in the same degree. This increase of sulphate is not ob- 

I 5 



178 ALKALINE PHOSPHATES: 

served in typhoid fever and scarlatina. It does not, therefore, depend 
merely on increase of temperature. Dr. Farkes suggests that in the 
blood, in acute rheumatism, there may exist a material richer in 
sulphur than albumen. Potash increases the tendency of this sub- 
stance to disintegrate; and hence, whenever liquor potasssB is given, 
the proportion of sulphates in the urine is augmented. 



Urinary 
constitneuts. 


Ck>nditlon in EfBsct produced by Liquor 
Rheumatic Fever. Potassn in large doses. 


Solids 


Increased Still more increased. 


Water 


Greatly diminished Slightly increased. 


Uric acid 


Increased Slightly increased. 


Sulphur 


In considerable quantity Probably increased. 


Chlorine 


Diminished Unaffected. 


Sulphuric acid 


Greatly increased Still more increased.* 



In many cases of skin disease, I have found the relative pro- 
portion of the sulphates to be considerably augmented. This is well 
illustrated in Analysis 5 (p. 169), which gives the composition of the 
urine of a boy suffering from eczema. 

226. — ^Excess and Defloiency of Alkaline Phosphates. — Much 
has already been said upon the quantity and origin of the alkaline 
phosphate in the urine; and I have brought forward evidence to 
show that the greater part of the phosphoric acid eliminated, is 
carried into the organism in the food. A certain proportion, how- 
ever, there can be little doubt, is formed in the body by the oxidation 
of the phosphorus of albuminous textures (nervous tissue ?). In dis- 
eases generally, the alterations which have been observed in the 
quantity of phosphate removed in the urine is to be attributed, to 
some extent, to the altered diet of the patient. It is reasonable to 
suppose that, in some conditions of the system in which a more than 
usual disintegration of tissues rich in phosphorous takes place, more 
phosphoric acid is formed in the organism than in health. This 
excess should be found in the urine in the form of alkaline phos- 
phate, and the amount ought to correspond to the activity of the 
changes taking place. By ascertaining the proportion, we should be 
able to form an estimate of the quantity of phosphorus oxidised ~ 
and therefore of the nerve-tissue disintegrated — of which it was a 
component part. The really difficult part of the inquiry is to ascer- 

* The influence of liquor potasss on the urine in rheumatic fever. 0*i/edl-CA«r. 
Reoiew;* voL xiiL, p. 248.) 



EXCESS AND DEFICIEKCT. 179 

tain how much of the total proportion of phosphate present is derived 
from the food, and how much is actually formed in the organism. 
The sulphuric acid is almost entirely produced in the body; and 
there is not, therefore, the same difficulty in estimating the amount 
of sulphur oxidised, as there is in the case of the phosphorus. 

Of late, the importance of this subject has been much increased 
by attempts to advance the experimental results already obtained in 
favour of the hypothesis, that the amount of phosphate excreted in 
the urine is to be regarded as an index of the activity of the nervous 
system. Those who labour to prove that all the changes in the body 
are the direct result of certain chemical decompositions, have not 
hesitated to bring forward these results in favour of their theory. 
It seems by some to have been regarded as a settled point, that the 
quantity of phosphate in the urine varies according to the amount 
of nervous tissue disintegrated; and it has been assumed that the 
quantity of work done by the brain is in direct proportion to the 
activity of the chemical changes going on in the nervous tissue. 
This question is obviously a most important one, and much more is 
involved in it than at first appears. I propose, therefore, to examine 
some of the most important facts which have been ascertained; and 
I think I shall be able to prove that, in this matter, speculation has, 
to some extent, taken the place of reasoning founded upon facts and 
experimental observations. 

226, Dr. Benoe Jones' Observations on the Alkaline Phos- 
phates.— Dr. Bence Jones, as is well known, has written several 
important papers upon this subject. The general conclusions to 
which he has arrived are the following : — 

" In delirium tremens, and in other delirium, a remarkable in- 
crease in the amount of sulphates in the urine was frequently ob- 
served; and the total phosphates were in the same cases occasionaUy 
remarkably diminished, 

" In acute inflammatory diseases of the nervous structures, during 
the most febrile symptoms, an increase was observed in the amount 
of sulphates in the urine; and the total amount of earthy and alkor 
line phosphates in these diseases appeared to he increased in the same 
proportion as the sulphates were increased, {^PhU. Trans," 1850, 
p. 66.) 

'* In fractures of the skull, the phosphatic salts increase only 



180 DELIRIUM TREMENS. 

when any inflammatory action occurs in the brain ; and in acute 
phrenitis, an excessive increase takes place. In delirium tremens, 
there is a marked deficiency of pJiosphateSf unless they are introduced 
with the ingesta; an excess is, however, met with in some functional 
aJBTections of the brain.'* 

These conclusions are founded upon analyses of 1,000 grains of 
urine, in eleven cases of delirium tremens and eight cases of acute 
inflammatory affections of the nervous centres. From these I select 
a few of the extremes. 

Delirium Tremens and other forms of Delirium. 



Case. 
8. Delirium Tremens — thirteenth day 

10. Poisoned by laudanum; delirium ) 
and excitement — second day ) 

4. Delirium Tremens — tenth day 

1 1. Delirium with phthisis — fourth night 



2. Inflammation of the brain — 
twelfth day 
Ditto — thirteenth day . 

6. Inflammation of lungs, with 
tubercles and violent head symp- 
toms — fourth day 
Ditto — sixth day 

The quantity of urine passed by the patients in twenty-four hours 
is not stated, nor is the amount of solid matter in 1,000 grains of 
urine, given. It is, therefore, not possible, from the above data, to 
form an estimate of the total quantity of phosphate removed from the 
organism in twenty-four hours. Although many of the results, as 
far as they go, certainly favour the above view, and especially when 
the numbers are considered with reference to the amount of solid 
matter estimated from the specific gravity, the increased excretion of 
the phosphates, in cases of inflammation of nervous structures, is not 
established by these observations. 

S27. The Author's Observations on the Phosphates. — I have 
estimated the quantity of phosphate in urine in various cases of 
disease. Some time since, I examined the urine of many patients in 



Sulphate of 

baryta perl ,000 

grains 

of urine. 

1310 


Specific 
gravity. 

1037-4 


Total 
phosphates. 

9-83 


7-83 


1026-8 


7-63 


17-31 


1024-74 


0-87 


6-97 


1024-2 


0-72 


iructureSf with Head Symptoms. 


3-96 


1018-7 


5-14 


11-23 


1027-26 


11-13 


8-55 


1027-85 


7-19 


7-81 


1026-1 


6-43 



PARALYSIS OF THE INSANE. 181 

St. Luke's Hospital, for Dr. Sutherland, with the view of ascertaining 
the proportion of phosphates excreted in different cases of mania, 
dementia, paralysis of the insane, &c. (" Med. Chur, Trans^ Vol. 
XXXVIIL, p. 261.) Forty-two analyses were made, and the following 
formula was filled up in each case. 

Water 

Solid matter 

Organic matter 

Saline matter 



Phosphate precipitated by chloride of cal- 
cium and ammonia . 



:! 



Some interesting facts were made out, and the quantity of phos- 
phates relatively to other constituents of the ash differed much from 
the healthy standard. Some of the results confirmed, as fu* as they 
went. Dr. Bence Jones' conclusions; but I do not think we can form 
a very positive conclusion from these data, seeing that, in some of the 
cases, the solid matter contained 10 or 12 per cent, of mixed phos- 
phate; while in others only 3 or 4 per cent, was found; and this 
variation did not always correspond to a difference in the symptoms. 
I subjoin a few of the most interesting results from two of the series 
of cases. 

228. Paraljrsis of the Inaasi.e.—Analym 21. From a man, 
aged 36. First attack. It lasted two months. Complete recovery. 

Analysis 22. — From a man, aged 45. First attack, of one month's 
duration. Not relieved. 

Analysis 23. From a man, aged 42. The specimen was taken 
on a day when he was very violent and noisy. 

Analysis 24. From the same, about three weeks afterwards, 
when the excitement had passed off. 

Analyses. 



Reaction 
Specific gravity 
Water 
Solid matter 
Fixed salts 
Phosphate of lime precipi- 
tated by chloride of cal- 
cium and ammonia 



21 22 

Acid. Feebly alkaline. 

1030 1015 

912-6 959-4 
87-4 100-00 40-6 lOO'OO 

21-42 24-50 13-31 327 

5-18 5-92 1-57 3*86 



182 





ACUTE 3£ANIA. 










23 


24 


Reaction 




Neutral 




Acid. 


Specific Gravity . 




1008 




1016 


Water . . 




988*6 




958-2 


Solid Matter . 




11-4 


100-00 


41-8 100-00 


Fixed Salts . 




4-74 


41-57 


8-45 20-21 


Phosphate of 


lime pre- 








cipitated by 


chloride of 








calcium and 




2-90 


25-44 


2-86 6*84 



It is important to observe that, in Analyses 23 and 24, 1,000 
grains of urine contained almost exactly the same quantity of phos- 
phates, but that the proportion to the other constituents was very 
different; the solid matter, in the first case, containing the very 
large proportion of 25*44 per cent ; in the second, only 6*84 per 
cent. 



220. Acute Uania, with Paroxysms.— ^naZ^m 25. From a 
man, aged 18, with meningitis. The present is the first attack, and 
has lasted three months. He recovered. 

Analysis 26. From a woman, aged 55. First attack, which has 
lasted about three months. She recovered. 

Analysis 27. From a man, aged 26. First attack, which has 
lasted six days. There was much exhaustion and emaciation. 
Weighs 7 St. 12 lb. Discharged uncured. 

Analysis 28. From a girl, aged 18. Second attack. Weighs 
only 6 St. 6 lb. 



Analyses. 



25 



26 



Reaction 






Acid. 


Feebly Acid. 


Specific Gravity . 






1020 


1023 


Water . 






945-8 


943-00 


Solid Matter . 






54-2 100-00 


57-60 


Fixed Salts . 






12-91 23-81 


1510 26-49 


Phosphate of lime 


pre- 






cipitated by 


chloride of 






calcium and 


ammonia . 


6-05 11-16 


7-14 12-52 



CHRONIC INFLAMMATION OF BRAIN. 183 

27 28 



Reaction 


. 


Acid. 




Acid. 


Specific Gravity . , 


. 


1033 




1028 


Water . 


• 


908-00 




931-6 


Solid Matter . 


• 


9200 




68-4 


Fixed Salts . 


• 


13-18 


U-32 


20-33 29-72 


Phosphate of lime 


pre- 








cipitated by chloride of 








calcium and ammonia • 


9-73 


10-57 


4-49 6-56 



It is much to be hoped that such observations will be further 
carried out by those who have the opportunity. Most valuable 
results would certainly be obtained, if the urine could be carefully 
collected for the twenty-four hours. 

The conclusions at which Dr. Sutherland arrives, in his paper 
above referred to, are the following : — 

1. A plus quantity of phosphates exists in the urine in the 
paroxysms of acute mania. 

2. A minus quantity exists in the stage of exhaustion in mania, 
in acute dementia, and in the third stage of paralysis of the insane. 

3. The plus and minus quantities of phosphates in the urine 
correspond with the quantitative analysis of the brain and of the 
blood ; for a plus quantity of phosphorus is found in the brain, and 
a slight excess of albumen in the blood of maniacal patients ; and a 
minus quantity of phosphorus and albumen are found in the brains 
of idiots, and a minus quantity of albumen in paralysis of the insane. 

4. The plus quantity of phosphates in the urine of cases of acute 
mania denotes the expenditure of nervous force, and is not a proof 
of the existence of acute inflammation in this disease. 

I have selected the following analyses from my note-book : — 

230. Chronic Inflammation of the Brain. — Arudym 29 shows 
the proportion of phosphates in the urine of a man, aged 34, who 
had been suffering from a tumour pressing on the veins of Galen, 
causing dropsy of the ventricles of the brain. There were many 
symptoms of chronic inflanmiation. Specific gravity, 1,018; acid. 

Analysis 30. Three weeks after the first analysis; acid, clear, 
pale; specific gravity, 1,015. 

Analysis 31. After another interval of three weeks; clear, natural 
colour specific gravity, 1,016. 



184 EPILEPSY. 



Analyses, 

29 30 31 



Water 96210 ) ...... 9563 

SoHd matter .... 37*90 100*00 P""""" 4370 100*00 

Organic matter . . . 27*09 74*12 3372 77*17 

Fixed salts .... 9*81 25*88 9*98 22*83 
Phosphate of lime precipitated ) 

by chloride of calcium and [ 2*74 7*22 3*53 3*92 8*97 
ammonia . • . ) 

281. Urine in Epilepsy.— ilnaZ^«i« 32. From a man suffering 
from epileptic fits, occurring every five or ten minutes, for seventeen 
hours. He breathed stertoriously the whole time, and no urine could 
be obtained during this period. Urine was obtained on the next 
day (June 10th); acid ; specific gravity, 1,024. Contained an abun- 
dant deposit of urates. 

Analysis 33. From the same patient, on the 12th ; acid, 1,024. 
Contains a good deal of pus. 

Analysis 34. From the same patient, on the 19th; alkaline, 1,017. 

Analysis 35. From a very intemperate patient, aged 59, who had 
epileptic fits every few minutes for thirty hours, followed by ex- 
haustion (twelve hours) and death. There was complete loss of 
consciousness. 

Analysis 36. From a man, aged 53, sufiering from slight general 
paralysis, with impaired speech (slight), intellect, and memory. 
Duration of illness, three years. Urine, pale, clear; no albumen; 
feebly acid; specific gravity, 1,009. 

Analyses, 



Water .... 




931*2 




927-2 




SoKd matter . 


. 


68*80 


] 00-00 


72-80 


100*00 


Organic matter . 


. 


58*35 


86*27 


51*01 


85*18 


Fixed salts 


. 


9*45 


1373 


1079 


14-82 


Phosphate precipitated by chloride ) 
of calcium and ammonia . . ( 


696 


10*11 


3-92 


5-38 




34 

958*8 
41*20 100-00 


35 
1000 


36 




Water .... 
Solid matter 


976-7 
23-30 


100*00 


Organic matter 


34*68 


8418 




17*46 


75-94 


Fixed salts . 


6*52 


15*82 




5-84 


25-06 


Phosphate precipitated by 
chloride of calcimn and 


2*15 


5*21 


8*86 


1*79 


7-68 


ammonia • 













I 1000-00 1000-00 



PUERPERAL MANIA. 185 

The quantity of phosphate in the first analysis is very great, 
especially when the small proportion of saline matter in the urine 
is taken into consideration. In Analysis 32, the ash consists of as 
much as 73*63 per cent, of phosphates; in 33, 36*30 per cent.; and 
in 34, the proportion is further diminished to 32*93 per cent. 

232. Urine in DeUrinm Tremens and Puerperal Mania. — 
Analysis 37. From a man, aged 36, on the fifth day of a slight 
attack of delirium tremens. He had had three severe attacks pre- 
viously. Clear, high coloured ; specific gravity, 1,015. The saline 
matter contained much sulphate, but not a trace of chloride. 

Analysis 38. From a man, aged 31, with delirium tremens of a 
fortnight's duration. Acid ; specific gravity, 1,020. 

Analysis 39. From a woman with puerperal mania. Acid; spe- 
cific gravity, 1,012. 

Analyses. 

37 38 39 

Water 959*32 

Solid matter 40-68 100*00 

Organic matter .... 

Fixed Salts .... 6*30 15*48 

Phosphate precipitated by chloride ) 2.93 7.20 7»66 3*40 

of calcium and ammonia . . ( 

233. Phosphates in the Urine in Health.— The following 
analyses show the varying quantity of the phosphates in the urine 
of a healthy man, 23 years of age. The large proportion of fixed salts 
depended upon the presence of much chloride of sodium. 

Analysis 40. Passed at half-past 2 p.m., immediately after dinner. 
Clear, natural colour; acid ; specific gravity, 1,015. 

Analysis 41. Passed at 6 p.m. on the same day, after three hours* 
reading. Acid; specific gravity, 1,011. 

Analysis 42. Passed at 2 p.m., immediately before dinner, on 
another day. Feebly acid; specific gravity, 1,022. 

Analysis 43. Passed at half-past 6 p.m., four hours after dinner. 
Acid ; specific gravity, 1,026. 

Analyses, 40 41 

Water 96360 972*4 

Solid matter 36*40 100*00 27*6 100*00 

Organic matter .... 14*75 68*00 19*89 72-07 

Fixed salts 11*65 32*00 7*71 27*93 

Phosphate of lime precipitated byl 0.62 7*19 1*92 6*96 
chloride of calcium and ammonia . j 



186 PHOSPHATES IN THE URINE. 

42 43 

. » -N 

Water 94380 936-80 

SoUd matter 56-20 lOO'OO 63*20 100-00 

Organic matter .... 37-80 67-26 36*30 6384 

Fixed salts 18-40 3274 2282 36-16 

Phosphate of lime precipitated by ) 2.40 4-27 6*22 9-84 
chloride of calcium and ammonia ) 

284. Oonolusions : The Phosx>hate8 in the Urine. — In the 
above analyses, can any relation be shown to exist between the 
symptoms present and the proportion of phosphoric acid ? In some, 
tiiere is, undoubtedly, an indication of such a relation; but in 
others, the proportion of phosphate is as great, although there was 
no evidence whatever of increased cerebral action or of inflammation. 
Without discussing the abstract question, I cannot think that the 
evidence at present obtained is sufficient to enable us to form a 
general conclusion. The inquiiy is more difficult than it at first 
sight appears to be. Before any reliable conclusion can be drawn, 
we must determine how much phosphate is derived from the food, 
and how much from the oxidation of phosphorus. We have, then, 
to ascertain the proportion formed in the muscular system, as well 
as in the nervous structures. Dr. Hammond, who has carried on 
very many valuable researches upon subjects of this nature, has 
found that the phosphates in the urine are greatly increased after 
active exercise. 

In any case of disease in which the excretion of an increased 
quantity of phosphates in the urine is suspected, we should ascertain — 

1. The total quantity of phosphoric acid, in combination with 
alkalies, in the urine passed in the twenty-four hours. 

2. The amount taken in the food within the same period of time. 
To be more exact, the earthy phosphate in the urine should also 

be estimated, as well as that which passes off in the faaces. 

I have not been able to ascertain that the quantity of phosphate 
excreted in the urine has ever been compared with the amount 
taken in the food, in diseases in which we should expect an in- 
creased disintegration of nervous tissue. Until experiments have 
been conducted so as to furnish us with positive data on this point, 
I do not think we are in a position to determine the question at 
issue. The results which have as yet been obtained are not suffi- 
ciently conclusive, as they fail to show even the total absolute amount 



CONCLUSIONS. 187 

of mixed phosphate eliminated from the body in twenty-four hours. 
One can hardly suppose that, in cases in which the greatest possible 
amount of disintregation of nervous tissue was occurring, a very great 
increase in the phosphate would be observed, considering how very 
much of the total quantity is derived from the food ; and of the 
comparatively small amount formed in the organism, a considerable 
proportion may originate in the muscular tissue. Very exact obser- 
vations upon the in and out going phosphates have therefore to be 
made before we can hope to have the fact established conclusively. 

I have ventured to occupy much time in the discussion of this 
question, and have gone more into detail than perhaps its import- 
ance, in the opinion of many practical men, demands. Still, when a 
long train of theories is constructed, the truth of which entirely 
depends upon the accuracy and correct interpretation of the experi- 
mental results from which it starts, it behoves us to examine 
rigorously into the nature of this foundation ; for until the funda- 
mental facts have been firmly established, we cannot allow ourselves 
to be led by the reasoning, however logical it may be ; or receive 
the conclusions, however closely they may follow on the premises. 
While, therefore, I do not deny that increased nervous action may be 
associated with the formation of an increased quantity of phosphoric 
acid, which is eliminated in the urine, I think that the facts hitherto 
advanced in favour of this view are by no means conclusive ; and I 
therefore hold that we are not yet in a position to form any theory 
upon the nature of the changes occurring in health or disease, in 
cerebral action, regarded from this point of view. 

235. Variation in Earthy Phospliates.— The proportion of earthy 
phosphates does not seem to vary much in disease. Dr. Bence Jones 
has shown that, in cases in which the alkaline phosphates are in- 
creased, there is no corresponding increase in the proportion of 
earthy phosphates. Much of the earthy phosphate eliminated in the 
urine in health is doubtless derived from the food, but a certain 
proportion is set free in the disintegration of the tissues, especially 
the osseous tissues. An increase of earthy phosphate is observed in 
the urine in some very rare cases of disease, in which the earthy 
matter of the bones is absorbed (moUities osHum). In one acute 
case of this disease, Dr. Bence Jones ("Phil, Tram.y^ 1848) obtained 
indistinct evidence of the presence of chlorine, and suggests that, in 



188 



EARTHY PHOSPHATES. 



future, this substance should be searched for, as it may possibly be 
directly concerned in the removal of the earthy material from bones. 
This specimen of urine contained a peculiar substance of an albu- 
minous nature. In IfiOO grains, there were 1'20 gr. of earthy 
phosphate; and the solid matter contained I'lS per cent. The 
analysis will be found in Ctoipter XI. 

236. Earthy Phosphates iiiNthe Urine: Mollities Ossiuin. — 
I have had opportunities of making analyses of the urine in two 
cases of moUities ossiuuL They were 'feipth well marked and fatal 
cases of the disease, and the specimens^ tf Tinne were obtained 
shortly before death. The patients were qurte^ bedridden, and the 
bones were so soft as to be readily indented by tfid 

Analysis 44. — This specimen of urine, from a moman suffering 
from mollities ossium, was sent to me by Dr. T. K. Chwmbers. The 
deposit contained oxalate of lime, with numerous stellate iaasses and 
separate crystals of earthy phosphate. Reaction, acid ;\ specific 
gravity, 1,014. 

Analysis 45. — Prom a case under the care of Dr. GreeniJ 
Morning specimen. 

Analysis 46. — Night specimen. 

Analyses, 



Water . 
Solid matter 

Urea . 

Extractives 

Fixed salts 

Earthy phosphates ) 
precipitated by > 
ammonia . . ) 

Alkaline phosphates ] 
precipitated by I 
solph. magnesia ( 
and ammonia . ) 

Triple phosphates fil- 
tered from the 
urine 



971-9 
28-1 
5-0 
10-22 
12-88 



100 
17-7 
36-3 
45-81 



965-2 
34-8 



1-186 4-21 



M3 4-21 



10000 



960-88 
39-12 100-00 



14-44 41-49 5-25 13-42 



•79 2-27 



•86 2-47 1-3 



•058 -16 



1-02 



3-32 



The large proportion of earthy phosphate in these analyses is a 
very interesting fact. In the first, the earthy actually exceeds the 



MOLLinES OSSIUM. 



189 



alkaline ph<»spliates; and in the second, it is nearly equal to it. In 
healthy urine, the alkaline phosphate usually amounts to from 
ten to fifteen times as much as the earthy phosphate. The inorganic 
salts, generally, are in considerable excess. 

237. Excess of, as distingrushed firom, mere Deposits of 
Earthy Phosphate. — Excess of Earthy Phosphate, which has been 
shown to be so uncommon, must be careftilly distinguished from the 
mere deposit of a certain amount in an insoluble form. The earthy 
phosphates very often form an insoluble deposit in the urine. The 
characters (tf these salts will be described under Urinary Deposits. 
It is hardly necessary to observe, that the deposit does not depend 
necessarily upon the excretion of an excessive quantity, but is often 
due to a change having occurred in some of the constituents which 
normally holds these salts in solution. A small quantity of deposit 
of earthy phofrj/hates makes a great show in urine; and it is obvious 
that a ver}' larj;c jiroportion might be held in solution in the urine, 
and thus f^/A]i*i detection, unless an analysis were made. In the 
case just cit'-d, X\\f^ c^f^ter part of the earthy phosphate was in solution 
in the Tjririf. It iii common enough to find the deposit in cases of 
djipepnsi waA ^(frwcrrk, toil it b ofteii spoken of as indicadiig the 
destfTictkifi t^ mrwvmmM^^tn these c-onditionB, the urine ofteii 
he&ftam nmtXfml m 4iK^|v '^ ^°^ ^^ causes the precipitation 
of i^ |lM9^i»iM« S^^m ^^ the quantity of the earthy 

^mi^Mt^ IM F'M^r \ ^ J ^^^^ eLrcumstaneeft which 

phosphate; and, although an 
ible iBap<:irtiinct\ its existence 
t nattir' 
cauf^ ! n in the 

n« 

i a Quan- 

Qstigation, 
ith rt^;ard 



Lind evening- 
'[ three huurs 




190 UBIKE IN DISEASE. 

Presence or absence of a deposit. If present, its microscopical 
characters. (Chapters XIII. et 8eq.) 

Presence of any of the substances to be described in Chapter XL 
— albumen, colouring matter of bile, sugar, &c. 

Estimation of the quantity of constituents in 1,000 grains of the 
mixed urine of twenty-four hours. From these data, the quantities 
passed in twenty-four hours are to be calculated. 

In 1,000 gr& In 24 hn. 

Water — — 

Solid matter — — 

Organic matter ..... — — 

Saline matter — — 

Urea — — 

Uric acid ...... — — 

Free acid — — 

Extractives, &c — — 

Alkaline phosphates, or phosphoric acid — — 

Earthy phosphates .... — — 

Sulphates, or sulphuric acid ... — — 

Chloride of sodium, or chlorine . . — — 

In particular diseases, it is very desirable to ascertain the 
quantity of one or two constituents removed in the twenty-four 
hours; and very much valuable information with regard to the nature 
of many diseases might be obtained by a number of careful and exact 
analyses of this kind. It is not necessary to fill up the above scheme 
in every case. In some, it would be desirable to know the amount 
of urea and uric acid with precision; in others, the amount of urea 
and sulphates. In diseases of the nervous system, the exact amount 
of alkaline phosphates passed in the twenty-four hours should be noted. 

Before the investigation is commenced, the observer should 
determine exactly the points he wishes to ascertain, construct a table, 
and fill up the several columns daily from his analysis-book. Every 
analysis should be made in precisely the same manner, and careful 
notes of the case should be recorded daily. If possible, analyses of 
the urine should be made after the patient is restored to health; so 
that the quantity of the various constituents eliminated from the 
body in a state of health, may be accurately compared with the 
amount removed during the disease, and the patient should be 
weighed at intervals while under observation (§ ). 



191 



CHAPTER XL 



Urine in Disease. Soluble Substances present in Urine 
IN Disease which do not exist in the Healthy Secre- 
tion. Albumen — Of Detecting the Presence of Alhumer^-^ 
Tests — Nitric Acid — Heat — AnomaUyus Restdts in Employ^ 
ing these Tests — Apparent Presence of Albumen in t/rine 
which contains none — Phosphate resembling Albumen — Uric 
Add resembling Albumen — Cases — Apparent Absence of 
Albumen in Urine which contains a large Quantity — Cases 
— Cause of the Precipitation of Albumen by Heat being pre^ 
vented by a Trace of Nitric Acid — Other Tests for Albumen 
— On Estimating the Quantity of Albumen — Peculiar Sub' 
stance in Urine allied to Albumen — Of the Importance of 
Albumen in Urine in a Clinical point of view^-Importance 
of Examining the Urine of Persons proposing to Assure their 
Lives — Ca^es in which the Presence of Albumen is not 
associated with Disease of the Secreting Struoture of the 
Kidney — On the Treatment of Cases of Albuminurea, Bile 
—Tests— Nitric Acid— Heller's Test—Pettenkofer's Test- 
Yellow Colour of the Cells, Sfc, in the Urinary Deposit — 
On the Clinical Importance of Bile in the Urine^-- Observations 
on the Treatment of Jaundice. 

239. Soluble SubstanoeB not present in Urine in Health. — 
I now pass on to the consideration of certain soluble substances not 
found in healthy urine, the presence of which is to be ascertained by 
the application of chemical tests to the urine. In many cases, 
however, our first suspicion of the existence of one or more of the 
substances now to be considered, is excited by certain peculiar 
characters affecting the deposit or the colour of the urine, or its 
peculiar smell or unusually high or low specific gravity may lead us to 



192 ALBUMEN IN URIKE. 

suspect the presence of substances which we know would give rise to 
such characters. The matters referred to, being perfectly soluble in 
the fluid, cannot be detected by microscopical examination; but, in 
many instances, we may infer their presence from the microscopical 
characters of certain bodies in the deposit. Thus, the detection of 
epithelial cells of a yellowish colour would lead us to test the urine 
for hiUary colouring matter ; if casts were found upon microscopical 
examination of the deposit, we should test for albumen ; if a certain 
kind of torula were present, we should have a suspicion that the 
urine contained sugar. In all cases, our conclusions must be verified 
by the application of appropriate tests, which will be presently 
considered. 

The most important soluble substances present in the urine in 
disease, but absent in the healthy secretion, are albumen, biliary 
constituents, and sugar. The clinical importance of these is so 
great, that they deserve special attention. 



Albumen. 

840. Of Albumen in the TTrine.— The occurrence of albumen 
has been regarded as a most important symptom ever since Dr. 
Bright showed that albumen was present in the urine in cases of 
disease of the kidneys, and pointed out the intimate connection 
between renal disease and dropsy. Albumen, it need scarcely be 
said, is absent from the urine of healthy persons, although now and 
then it may be detected for a short period of time in the urine of 
individuals who are not suffering from any serious or permanent 
derangement of the health. The presence of albumen must always 
be regarded by the physician as a point of serious importance, 
although at the same time, per se, it cannot be taken as evidence 
of the existence of any organic lesion, unless it has been clearly 
detected from day to day for a certain time. Many of the causes 
which give rise to the escape of serum from the vessels in other 
parts of the body, independent of disease, will determine its tran- 
sudation through the walls of the renal capillaries, and, as a matter 
of course, it will be found in the urine. 

To recognise with certainty the presence of a substance in the 
urine having so important a bearing upon the discovery and inter- 
pretation of certain morbid processes, as albumen, is obviously a 



TESTS FOR ALBUMEN. 193 

point of the utmost importance to the practitioner. In the ex- 
amination of the urine of patients, certain tests are at once applied, 
in order to determine if this substance be present or absent. In 
the majority of cases, positive information is easily obtained ; but 
occasionally an instance occurs in which, without great care, an 
erroneous conclusion is likely to be arrived at although the proper 
tests have been applied to the urine. As this question is one of 
very great practical importance, and of much interest, I propose to 
consider it at somewhat greater length than is usual in works 
devoted to the clinical examination of urine. 

The reactions to which I shall refer are not imaginary, but have 
actually occurred to me. I have known instances in which albumen 
was stated to be absent when the urine contained a very large 
quantity; and other specimens have fallen under my notice, which, 
although they really contained none, yielded a precipitate having 
many of the characters of albumen. Let me, then, speak of the 
phenomena in regular order. 



Tests fob Albumen in Ubine. 

241. Nitric Acid.— 1. Albumen is usuaUy precipitated from its 
solution upon the addition of a few drops of nitric add. Heller 
recommended that the acid should be allowed to flow to the bottom 
of the tube containing the urine. In this manner, three strata are 
formed, the lowest stratum consisting of the pure acid, above which 
is the precipitated albumen, while the upper stratum consists of the 
fluid containing the albumen uncoagulated. 

It must be remembered that two or three drops of nitric acid to 
about a drachm of albuminous urine in a test tube will produce a 
precipitate of albumen which will be dissolved on agitation, while, 
on the other hand, about half as much strong nitric acid as there is 
of urine will re-dissolve the precipitate of albumen, unless the quan- 
tity present be excessive. Albumen precipitated by nitric acid is 
soluble in weak nitric acid and in a considerable excess of urine, 
and it is also soluble in strong nitric acid. It is therefore necessary, 
in employing this test, to add from ten to fifteen drops of the 
strong acid to about a drachm of the urine suspected to contain 
albumen. 

K 



194 T£SrS FOB ALBX7MEN 

d42. Heat. — 2. AUmmm is also generally coagulated by the 
appUcaUon of heat (140° to 167° Fahr.). If very dilute, a higher 
temperature is required. The best way of testing urine by heat is 
the following : — ^An ordinary test-tube is about half filled with the 
urine, and is to be held between the finger and thumb by the lower 
part Heat is applied to a point near the surface of the fluid ; the 
tube being shaken a little at the time, to prevent the glass being 
cracked. The slightest precipitate cannot fEiil to be observed, as the 
fluid below remains perfectly unchanged. When urates are present, 
this plan is very useful, as we get three distinct strata ; the upper 
one more or less turbid or milky, consisting of coagulated albumen ; 
the next clear, in consequence of the solution of the urates at a 
temperature somewhat below that necessary for the coagulation of 
the albumen ; and lastly, at the lower part of the tube, the unchanged 
deposit of urates, 

248. EiEBOt of Heat on Alkaline Albaminons TTrine. — 3. If 
the solution of albumen be alkaline^ no precipitate will be produced 
by heat. We are, therefore, generally directed to neutralise the 
alkali by an add before heat is applied. If excess of acid (ten to 
fifteen drops of the strong acid to a drachm of urine) be added, the 
albumen is, of course, precipitated in the insoluble form, without 
the application of heat. 

244. Discrepancies.— Frequently specimens of urine are met with 
which exhibit one or more of the following peculiarities, tending to 
make us believe either that albumen is present when it is not, or to 
cause us to conclude that it is absent when the urine contains it. 

1. Upon the application of heat, the specimen may become tur- 
bid, in consequence of the precipitate of phosphate. The reaction 
of the urine in this case would generally be neutral or feebly alkaline; 
but sometimes urine depositing phosphate on the application of heat 
is of a decidedly acid reaction (§ 161). 

2. Upon the addition of nitric acid, the specimen becomes turbid, 
in consequence of the decomposition of the urates held in solution 
in the urine, and the deposition of uric add in a granular state. 
If the acidified urine be boiled, it usually becomes clear, with the 
development of a pinkish or brown colour, consequent upon the 
decomposition of the uric acid and certain colouring matters. 



IN THE URINE. 195 

3. Upon adding nitric acid to some specimens of urine of high 
specific gravity, an abundant precipitate of a crystalline character is 
produced. This consists of Nitrate of Urea, and is easily recognised 
by its crystalline character. It seldom appears immediately, and 
is hardly likely to be mistaken for albumen. Microscopical exam- 
ination will at once determine the nature of the precipitate (§ 128). 

4. After adding a drop or two of nitric acid to urine suspected 
to contain albumen, in order to render it distinctly acid, no preci- 
pitate is produced upon boiling, although a large quantity of albumen 
may be present. This is constantly observed in all specimens of 
albuminous urine, and shows the importance of never boiling urine 
suspected to contain albumen in a tube which may contain, by 
accident, a drop or two of nitric acid. 

5. Cubebs, copaiba, and some other resinous substances, taken 
internally, are said to give rise to precipitates in the urine which 
are liable to be mistaken for albumen. 

We have, then, to consider — 

1. Cases in which a precipitate is produced in urine containing 
no albumen. 

2. Cases in which no precipitate is produced, although the urine 
contains albumen. 



1. A Fbeoipitate Fboducei) in Ubine coNTAiNiNa NO Albumen. 

246. Phosphate resemblingr Albumen. — ^The precipitate of 
phosphates is very readily distinguished from albumen by its solu- 
bility in a little acid. Upon the addition of a few drops of nitric 
acid, the turbidity produced by heat instantly disappears, and the 
solution becomes perfectly clear. 

246. TTrio Add resemblingr Albumen. — ^When a precipitate of 
uric acid in a minute state of division is caused in consequence of 
the decomposition of the urates by nitric acid, its nature may be 
ascertained by allowing the mixture to stand for some time, when 
the minute granules gradually increase in size, and at length become 
crystals, the nature of which is at once recognised upon microscopical 
examination. In some cases, the crystals may be seen to form under 
the microscope. This precipitation of uric acid on adding nitric acid 
often leads to mistakes, and albumen is stated to be present in urine 

K 3 



196 ALBUMEN APFARENTLT PRESENT 

which really does not contain a trace. Several cases of this preci- 
pitate have occurred to myself, and I have heard of many others in 
the practice of friends. It has happened in the wards of our hos- 
pital, that a precipitate produced hy nitric acid has led the 
clinical clerk to state that alhumen was present in the urine, when, 
upon being submitted to examination subsequently before the class, 
no precipitate could be obtained. The faUacy was explained as 
above. 

Dr. 6. 0. Rees has met with urine affording this precipitate of 
uric acid on the addition of nitric acid, in cases of typhoid fever. 
Most of the instances which I have observed occurred in cases of 
liver-affection. I extract two or three as examples. 

247. Speciinens of Urine yieldingr a Precipitate resemblingr 
Albumen but composed of TJric Acid. — Urine from a Patient 
suffering from large Hydatid Tumours of the Liver. A small 
quantity of the urine was filtered, and, upon the addition of a little 
nitric acid, a precipitate was produced. After standing a little 
while, this was examined by the microscope, and found to consist of 
minute crystals of uric acid. These were dissolved upon the appli- 
cation of heat ; but, as the solution cooled, they were deposited again 
in the form of much larger crystals. 

A specimen of urine exhibiting the same peculiarity contained 
excess of urea. Upon the addition of half its bulk of nitric acid, the 
mixture became nearly solid, from the formation of crystals of nitrate 
of urea. The deposit in this instance consisted partly of urate of 
soda. 

Another example, of which I have kept notes, occurred in a man 
aged 49, suffering from rheumatic fever. The urine was acid, spe- 
cific gravity 1027, and contained much urate of soda. The prac- 
titioner who first saw the case boiled a portion of the urine. It 
remained clear ; and he said, therefore, that it contained no albumen. 
A physician afterwards tested a portion of the same urine with nitric 
acid; and, finding that an abundant precipitate was produced, 
affirmed that much albumen was present. The deposit produced by 
nitric acid was found, by subsequent examination, to be dissolved 
by heat ; and, when a portion was examined in the microscope, its 
true nature was decided by the presence of numerous uric acid 
crystals. 



IN URINE WHICH DOES NOT CONTAIN IT. 197 

2. No Pbbcipitatb Produced in Ubinb containing Albumen. 

248. Albumen not coagulated by heat when a little nitric acid 
is present. Upon the careful addition of a drop of nitric acid, the 
precipitate at first formed when the acid comes in contact with the 
urine, slowly dissolves as it descends towards the bottom. Upon 
boiling this oAdified solution, no precipitation of albumen will take 
place. Upon the further addition, however, of nitric acid, the 
albumen is precipitated. 

This reaction has often led to mistakes. Not unfrequently albu- 
minous urine has been poured into a test-tube which contained a 
trace of the nitric acid remaining from some previous experiment ; 
and, upon boiling the mixture under these circumstances, no preci- 
pitate of albumen has occurred. In some cases, two or three drops 
of acid are added, according to directions often given for the very 
purpose of acidifying the urine previous to boiling it. This fact 
must not be forgotten; — that if a few -drops of a dilute solution 
of nitric acid be added to a portion of albuminous urine in a test- 
tube, and the mixture boiled^ no precipitate will be produced. In 
fact, the addition of a little dilute nitric acid will prevent the coa- 
gulation of albumen by heat 

249. Explanation of this Reaction. — Dr. Bence Jones was, I 
believe, the first to offer an explanation of this fact, in a communi- 
cation to the editor of the Medical Gazette (vol. xxvii., p. 289). 
Dr. Jones thinks that the solution of the albumen is owing to the 
formation of a nitrate of albumen which is soluble in a weak solution 
of nitric acid, even although boiling, but insoluble in a mixture of 
acid of moderate strength. Dr. Bence Jones has also shown that 
albumen is not always precipitated from very acid urine upon the 
application of heat. 

From observations I have made, however, I have been led to 
conclude that the above result depends rather upon the decomposition 
of the phosphates by the nitric acid, and the consequent development 
of free phosphoric acid in which acid albumen is freely soluble. 
This view was confirmed by some experiments which I made some 
time since on the subject, and which have been many times repeated. 
A weak solution of albumen was treated with a few drops of chloride 
of calcium, and afterwards with a little ammonia. After having 



198 OTHSS TI5IS IDR ALBCXESL 

stood for twentj-foor hoon, it wis filtered. In this maimer^ anj 
solable phoq>hat€8 present were rcmoTed. The sf^tion was then 
tested 18 follows: — 

1. Albumen wis precipitated br the ipplicitioii of heal^ or bj 
the addition of nitric add, as nsnall j occurs. 

2. A Teiy small qnantitj of dilate nitric add did not prevent 
the coagulation of the albnmai bj heat. 

3. After the addition of a few drops of phoaphoric add, the fluid 
no longer coagulated upon being IxHled. 

Some of the same solution as the aboTe, whidi had not been 
treated with chloride of caldum and ammonia, affinded the same 
results upon the application of the tests as other albuminous 
solutions. A few drops of a weak solution of nitric add, or a little 
phosphoric add, prorented the predpitation of the albumen by heat 
The addition of phosphoric add to an albuminous solution, or a 
soluble phosphate and a little nitric add, prevented the predpi- 
tation of the albumen by heat 

These results, therefore, led me to condude that a trace of nitric 
add prevents the coagulation of a moderately strong solution of 
albumen by heat, in consequence of decomposing the phosphates 
and setting free phosphoric add, in which the albumen is soluble. 
When, however, excess of nitric add is added, its action pre- 
dominates over that of the phosphoric add, and the albumen is 
predpitated. 

At the same time, it must be admitted that there are several 
facts connected with the behaviour of weak solutions of albumen 
with acid, and under the influence of heat, which are not satis- 
fiEu:torily explained; and forms of albumen having different reactions 
are from time to time met with. The whole subject requires further 
careful investigation. 

850. Other Tests fbr Albumen.— Albumen is predpitated from 
its solutions by alcohol, alum, and many metallic salts, as those of 
lead, mercury, copper, and silver. The presence of grape sugar 
prevents albumen from being precipitated by sulphate of copper 
and liquor potassse. The mixture forms a dark blue solution. In 
its turn the presence of the albumen prevents the reduction of the 
oxide to the state of snb-oxide when the mixture is boiled (see test 
for sugar). Bichloride of mercury is employed as a test, and ferro- 



ALBUMINOUS URINE. 199 

cyanide of potassium precipitates a solution of albumen to which 
acetic add has been added. These salts will, however, produce preci- 
pitates in solutions of other substances allied to albumen. 

251. On Estimatingr the dtiazitity of Albtunen in Urine. — 
The quantity of albumen varies much in different cases, sometimes 
amounting to a mere trace ; while, in other instances, a proportion 
not much inferior to that present in serum has been met with. In 
one case as much as 545 grains were excreted in 24 hours (Farkes). 
In order to estimate the quantity of albumen, it is only necessary to 
add a little acetic acid, by which any combination of albumen with 
alkali is decomposed, and heat the urine in a water-bath to a tem- 
perature of 194°, or until it boils. The precipitate is to be collected 
on a weighed filter, well washed, dried, and weighed. The albumen 
always contains a small quantity of earthy salts, which are obtained 
by incineration. The residue must be deducted from the weight of 
the dried precipitate. 

Albuminous Urine^ from a patient with acute inflammation of 
the kidney. The deposit contained numerous granular casts, but no 
fat-cells were present; specific gravity, 1015; acid. The albumen 
coagulated by heat and nitric acid. 

Analysis 47. 

In 100 parts 
of solids. 

Water 952-00 

Solid Matter 48-00 100-00 

Urea 13'052 27-19 

Albumen, mucus, and uric acid . 19*204 40-00 

Extractives .... 12*864 26*80 

Alkaline salts .... 2*784 5*80 

Earthy salts .... '096 -20 

252. Pecnliar Forms of Albumen. — Scherer describes a variety 
of albumen which is only imperfectly coagulated by heat. It is 
possible, however, that many of the peculiar reactions met with from 
time to time, depend upon the presence of other substances dissolved 
with the albumen, rather than upon any peculiar properties of the 
albumen itself, or the existence of a variety of this substance. The 
reaction of different solutions of albumen is a subject well worthy of 
minute investigation. 



200 



NEW SUBSTANCES ALLIED TO ALBUMEN. 



258. New Substance allied to Albumen.— Dr. Bence Jones 
obtained a new substance allied to albumen from the urine of a 
patient (under the care of Dr. Watson and Dr. Maclntyre) suflfering 
from mollities ossium. The urine was slightly acid ; specific gravity, 
1034-2 (Phil Trans, for 1848, p. 55). The deposit consisted of 
phosphate of lime, oxalate of lime, and cylinders of fibrine. Phos- 
phates were precipitated by heat; but the urine was cleared by 
adding a drop of acid. No precipitate was produced by nitric acid ; 
but, after being heated and left to cool, it became solid. The solid 
material was redissolved by heat, and precipitated again when the 
mixture became cool. On some days, the urine coagulated by boiling; 
on others, prolonged boiling produced no change. A specimen, 
which did not coagulate by boiling, was carefully examined. It was 
acid; specific gravity, 1039*6. It contained much urate of ammonia, 
phosphate of lime, and oxalate of lime. The urine contained — 



890-72 


In 100 partft 
of solids. 


109-28 


10000 


66-97 


61-28 


29-90 


27-36 


'96 


•87 


1-20 


1-18 


3-83 


3-50 


2-10 


1-92 


4-45 


4-07 



Water . 

Solid matter . 
New substance 
Urea . 
Uric acid . 
Earthy phosphate 
Chloride of sodium 
Sulphate of potash 
Alkaline phosphate 



The new substance was precipitated from the urine by alcohol, 
well washed, and ultimate analyses were made. It contained 1-09 
per cent, of sulphur, and -20 per cent, of phosphorus. This 
substance is the hydrated deutoxide of albumen. It was soluble in 
boiling water, and the precipitate produced by nitric acid was re- 
dissolved by heat, and it formed again as the mixture cooled. A 
similar substance occurs in small quantity in pus, and in the 
secretion from the vesiculaB seminales. The urine contained 66*97 
parts per 1000 of this substance — an amount equal to the quantity 
of albumen in the blood. The patient was passing about thirty-five 
ounces of urine daily, which would contain upwards of 1000 grains, 
or more than two ounces of this new material. 

Dr. Bence Jones recommends that this substance should be 



CLINICAL IMPORTANCE OF ALBUMEN. 201 

looked for again in acute cases of moUities ossium. He suggests that 
the reddening of the urine upon the addition of nitric acid might 
lead to its detection. 

254. Of the importance of Albumen in the Urine in a dinioal 
point of view. — The presence of albumen in the urine may be due 
to — 1, temporary or permanent changes in the secreting structure 
of the kidney itself; or, 2, to changes occurring irrespective of the 
kidney, as alterations in the character of the blood, pressure of 
tumors upon the cava, &c. (§ 256). 

Albumen in thb Urine dependent upon Acute oe Cheonic 
Changes in the Kidney. 

In the majority of cases, in which the urine contains a very 
large quantity of albumen, and especially if the urine be of 
specific gravity of 1020 or higher, and of a dark brown colour or 
smoky hue, caused by the action of the acid of the urine upon the 
colouring matter of the blood, the inference will be that the case is 
an acute one, and that this large quantity of albumen has not been 
passing away from the kidney for any length of time. In very many 
of these cases blood is present. By far the majority of acute cases 
recover if the patients are placed under favourable circumstances. 
In some instances, however, the circulation through the kidney 
becomes more and more obstructed ; the urinary constituents accu- 
mulate in the blood and seriously impair the various actions going 
on in the body, and especially affect the nervous system; and death 
results, probably preceded by coma and sometimes by convulsions 
{see p. 68, also my " Archives,''^ Vol. II., p. 286). Occasionally pus is 
formed in considerable quantity in the uriniferous tubes. Sometimes 
the acute stage passes off, and the albumen, although it diminishes in 
quantity, does not entirely disappear from the urine, and the acute 
attack afterwards proves to have been the commencement of chronic 
kidney-disease. 

In chronic fatty degeneration of the kidney there is often also 
a very large quantity of albumen, but the urine is pale and of low 
specific gravity. The history of the case, the appearance of the 
patient, the symptoms present, and the microscopical characters of 
the deposit {see '* casts '^ render it almost impossible to mistake a 
case of chronic fatty degeneration for one of acute inflammation of 

K 5 



202 CLINICAL IMPORTANCE 

the kidney caused by cold, or following scarlet or other ernptiye 
fever. For the microscopical characters of the urine, which are 
exceedingly distinctive in these cases, see Plates XV., XVI., and 
XVIII., of the "Illustrations of urine, urinary deposits, and calculi,^* 
If the quantity of albumen be small, amounting merely to 
milkiness or opalescence when heat is applied, or nitric acid added 
to the urine, and especially if the urine be pale and of specific 
gravity 1012 or lower, we should suspect that the lesion giving rise 
to the escape of the albumen was chronic, and probably depended 
upon contracted kidney. If the proportion of urea to the other 
constituents of the solid matter were large, we should form a more 
favourable opinion than if the percentage of urea in the solid matter 
were very much less than in health. In the latter case, a great part 
of the renal structure would probably be involved; but, in the 
former, there would be reason to think the disease had only affected 
a certain number of the secreting tubules. There are, however, 
some exceptions to these general statements. Patients have passed 
small quantities of albumen in the urine for many months, and it 
has afterwards disappeared. In other cases the progress of the 
disease is exceedingly slow. I have known a man pass urine of the 
character above mentioned for upwards of twelve years; and I believe 
that this might go on for twenty years, or even longer, the patient 
perhaps dying at last of some other malady. It must, however, 
always be borne in mind that such persons are more likely to suffer 
from exhausting influences, cold, fatigue, &c., than others. 

255. Importance of Examining the TJrizie of Pez«ons Fro- 
posingr to Assure their Lives. — It is very important that the 
medical officers of Life Insurances should be aware that there are 
many instances of persons having chronic disease of the kidney, who 
are not themselves aware of it. Neither is there in many of these 
cases anything in the appearance or history of the person that would 
cause the physician to suspect the true nature of the case. The 
discovery of albumen in the urine, or of casts in the deposit, is 
sometimes the only point which leads the practitioner to a correct 
knowledge of the doubtful nature of the life. Now, if one of these 
persons experienced a severe attack of catarrh, his life might be 
endangered; and exposure to cold would be very likely to set up 
acute inflammation of the kidneys, already impaired by disease, and 



OF ALBUMEN IN THE URINE. 203. 

might thus prove fatal. The only way to discover such a condition, is 
to institute a careful examination of the urine in every case; but, to 
carry this out practically, it must be confessed, there are many 
difficulties, and often objections on the part of the proposer. If, 
however, the medical referee should have the slightest reason for 
suspecting the existence of renal disease, he is quite justified in 
insisting upon the necessity of examining the urine. 

A microscopic examination of the deposit in the urine will 
throw much light upon almost all cases of albuminuria, and 
enable us to diagnose the condition with much greater precision 
than is possible from a mere chemical examination. We cannot, 
however, be too cautious in arriving at a prognosis in these cases. 
Every circumstance connected with the individual case must be 
carefully considered, and the state of nutrition, the progress the 
disease has made in a given time, the state of other organs, the con- 
stitution of the patient, his circumstances, temperament, &c., must 
be passed in review. The practitioner should always express a very 
guarded opinion as to the probable duration of life, for under 
favourable circumstances life may be prolonged for many years, 
while an attack of pneumonia, or fever, or even common catarrh, 
occurring at any time, might prove fatal, although the patient was 
considered by himself and by his friends to be in good health at the 
time of the attack. I have seen apparently slight cases die within a 
very short period of time, and very severe cases of disease, accom- 
panied with general dropsy, and ascites, with great prostration, and 
diarrhoea, wliich were not expected to live a week, rally, recover 
from the dropsy, and live for some years afterwards, in the enjoy- 
ment of far better health than the most hopeful practitioner would 
have anticipated. 

Albumen in the Ueinb not dependent upon Renal Disease. 

256. Cases in which the Presence of Albumen is not asso- 
ciated with Disease of the Secretingr Stractore of the Kidney. — 
Albumen is always found in small quantity in urine containing pus. 
We shall therefore meet with it in cases of inflammation of the 
kidney (pyelitis), and in cases of inflammation of the bladder and of 
the mucous membrane of the urinary organs generally. Whenever 
blood is present in the urine albumen is detected; for, if blood- 



204 ALBUMEN IN THE URINE, 

corpuscles escape from raptured capillaries, a certain quantity of 
serum must at the same time pass through the fissures. The 
colouring matter of the hlood is sometimes passed in urine in a state 
of solution; hut in this case, also, a certain quantity of albumen is 
present. 

Dr. Bence Jones detected albumen in the urine of a patient who 
passed spermatozoa. The urine passed in the morning contained 
spermatozoa and albumen. The evening specimen contained neither. 
On a subsequent examination, no albumen could be detected. 

I have detected albumen in many cases of pneumonia during the 
period of hepatisation of the lung. It is present, also, in the 
specimens of urine first passed after the period of suppression in 
cholera. In some cases of acute rheumatism with pericarditis it is 
observed; and it has been occasionally detected in continued fever. 
In puerperal fever it is often met with, and in puerperal convulsions 
it is almost constantly present. Dr. Lever found that it was absent 
in only one case out of fifty. The pressure of the gravid uterus is 
probably a cause of the albuminous urine met with in some cases of 
pregnancy, but it cannot always be referred to the same cause, for it 
sometimes occurs at an early period of pregnancy, when the uterus 
is too small to exert much pressure. Dr. Tyler Smith considers that 
it is to be accounted for by an influence exerted upon the nerves, in 
those cases in which it is not connected with organic disease. Out 
of 112 specimens of urine from pregnant women, Dr. H. Van Arsdale 
and Dr. Elliott only found albumen present in two instances. {^^New 
York Journal of Medieiney^ 1856). 

After intermittent fevers albumen frequently escapes in the 
urine. In cases in which any physical impediment to the return of 
blood in the emulgent veins or inferior cava exists, and in some cases 
of obstructed portal circulation, as in cirrhosis of the liver, traces of 
albumen may be detected in the urine. In anaemia, and in cases of 
dropsy depending upon an impoverished state of the blood, albumen 
is often passed. Sometimes a large quantity of blood extractive 
matter is also present. After long continued haBmorrhages, when 
dropsy occurs, we not unfrequently find albumen in the urine. In 
these cases it does not depend upon kidney-disease, but upon the 
state of the blood. Just as serum escapes from the capillaries of 
various tissues of the body, it is prone to transude through the renal 
vessels. Lastly, in persons who have suffered for many years from 



IK PNEUMONIA, CHOLERA, &C. 205 

affections which produce alterations in the capillary walls, albumen 
may pass off in the urine; and towards the termination of exhausting 
diseases it is frequently present. 

In cases in which the presence of albumen depends upon 
obstruction to the circulation in the kidney, the impediment may be 
functional or temporary, or it may be organic and permanent. As 
examples of the presence of albumen depending upon temporary 
congestion, may be adduced certain cases of pneumonia and cholera, 
cases of acute dropsy, and of dropsy consequent upon scarlatina, with 
many others. Fatty degeneration and chronic nephritis may be 
brought forward as instances of structural disease, which permanently 
affects the circulation of the blood through the kidney, so as to cause 
albumen to transude through the capillary vessels. 

In the majority of cases, the vessels of the Malpighian tuft 
doubtless form the precise seat of the escape of albumen; but there 
are reasons for believing that albumen sometimes passes from the 
capillaries surrounding the convoluted portion of the uriniferous 
tubes, and in some instances from those in contact with the straight 
portion. {^^ Archives of Medicine" VoL I., p. 300.) 

In most cases in which albumen occurs in the urine, casts of the 
uriniferous tubes are also found; for with the serum a certain 
quantity of coagulable material transudes or is found in the tube, 
and this becomes solid while it lies in the tube, of which it thus 
takes a mould, and entangles in its meshes any loose bodies, as 
particles of epithelium, &c., which may happen to be in the tube at 
the time. In the first series of cases alluded to, casts are often 
absent, or, if formed, they are perfectly transparent. On the other 
hand, where the structure of the kidney is altered, the casts often 
afford evidence of the nature of the lesion. This part of the subject 
will be considered in Chapter XIV. Albumen is, however, often 
present without any deposit, so that for its detection we must rely 
solely on chemical tests. 

Treatment op Albuminuria. 

257. On the Treatment of Cases of Albtiminuria.-~It is not 
possible, in a work of this kind, to enter fully into the treatment of 
cases in which albumen is passed in the urine ; but it may not be 
altogether useless to offer a few brief observations upon the general 



ON THE TREATMENT 

principles which should be earned oat The subject may be thus 
divided : — 

1. Acute cases in which the kidney is affected. 

2. Chronic cases in which the kidney is affected. 

3. Gases in which the kidney is not affected. 

Treatment of Acute Albuminuria, — The treatment of the first 
class of cases is now well understood. Cases of acute dropsy, from 
exposure to cold and wet; dropsy after scarlatina, measles, or other 
eruptive fever; and all cases in which the kidney is acutely affected, 
80 that but a small quantity of water containing a large quantity of 
albumen is secreted — come under this head. In all such cases the 
kidney requires rest, and the physician endeavours to excite the 
action of those emunctories by which urinary constituents may be 
eliminated — ^these are the skin and the intestinal canals. Hot air 
baths, sudorifics, and purgatives (compound jalap powder, elaterium, 
or gamboge), often give great relief in this class of cases. At the 
same time, cupping over the kidneys is often required to relieve the 
intense local congestion. When the acute symptoms have subsided, 
and the water has increased in quantity, while the albumen has 
diminished, especially in cases in which much blood has been carried 
off in the urine, tonics should be given; but by far the most valuable 
remedy I have employed under these circumstances, as well as in 
many chronic diseases of the kidney, is the tincture of the sesqui- 
chloride of iron. 

But, from time to time, cases of acute inflammation of the kidney 
are seen, in which the acute symptoms do not pass off as rapidly as 
usual. Instead of the dropsy disappearing within a week or a fort- 
night, it persists, or the swelling becomes greater, and the urine does 
not increase in quantity, or lose the large proportion of albumen it 
contains. Many of these cases depend upon the general state of the 
health, and, no doubt, are due to the poor state of the blood, which 
renders absorption impossible. Often we shall find the digestive 
organs out of order, and the greatest benefit results from the use of 
pepsin (§ 315) and dilute hydrochloric acid, as well as the tincture of 
sesquichloride of iron. The appetite improves, the blood becomes more 
healthy, and then the effused serum is soon absorbed. In one patient 
suffering from acute dropsy (W. S., Vol. III., p. 7), each leg measured 
eighteen inches in circumference a month after the attack had com- 
menced, and the efiusion seemed to be increasing. In a month after, 



OP ALBUMINURIA. 207 

the treatment had been altered as above, the circumference of the 
legs had diminished to thirteen inches, and in this short time several 
pints of serum must have been removed from the areolar tissue of the 
body generally. The quantity of urine increased from about twenty 
to fifty ounces in the twenty-four hours. 

Treatment of Cases of Chronic Albuminuria. This condition may 
depend upon several different morbid changes. The two most com- 
mon are fatty degeneration and chronic contraction. Many cases of 
the former condition go on for years. I know one case of a patient 
who has for fifteen years been suffering from fatty kidney, passing a 
considerable quantity of albumen during the whole period. Although 
his general health is affected, and there is some degree of dropsy, there 
are no urgent symptoms. The disease must, of course, terminate fatally, 
but in these cases we must be very cautious in giving an opinion as 
to the length of time a patient is likely to live. I have seen several 
cases of bad general dropsy, depending upon fatty kidney and chronic 
contraction, rally and go on for years after it was supposed the 
disease would have terminated fatally. Under favourable circum- 
stances, it appears the disease makes very slow progress, and, in 
many cases, there is reason to believe that several of the uriniferous 
tubes of some or both kidneys are in a tolerably sound state. In 
treating a case of fatty kidney, attention must be paid to the general 
state of health. Nutritious diet, plenty of fresh air, the sea side or 
a sea voyage, often produce marked benefit. Of medicines, the 
tincture of sesquichloride of iron is among the most valuable, but it 
should be continued for many months at a time. Glycerine is a 
remedy which improves the health in some of these cases. Where 
the stomach is irritable at an early period of the disease, alkalies 
and hydrocyanic acid afford relief ; but pepsin is of great value in 
some cases, and at once relieves the dyspeptic symptoms. Towards 
the close of many of these cases vomiting is often the most distressing 
symptom, and it is most difficult to relieve or control it. Creasote, 
ice, and other remedies may be tried, but the food should be given in 
tea-spoonfuls only at a time. 

Many cases of fatty degeneration of the kidney seem to be con- 
nected with the scrofulous habit, and in the early stages of the 
disease the general treatment is the same in both conditions. 
Although, from the nature of the disease, some might be inclined to 
deny patients fatty matter, in the early stages cod liver oil, and 



208 ON THE TREATMENT 

everything likely to improve general nutrition, is advantageous. 
The fatty matter found in the fatty kidney is not ordinary fat, like 
that existing in adipose tissue, but it is very rich in cholestissue, as 
is the case with the fatty matter found in all tissues undergoing 
what is termed fatty degeneration. Tubercle also contains choles- 
tissue. We must not, therefore, deny to patients suffering from this 
malady food rich in fatty matter, on the ground that too much fat is 
being formed in the kidney. If nutrition be improved, the tendency 
to the morbid change will diminish. I doubt if fatty matter in the 
food exerts more influence on the kidney in these cases than it does 
upon the liver in cases of phthisis. We should certainly act upon a 
wrong principle if we discarded the use of fats in the latter malady 
because there was a fear of promoting the formation of fatty liver. 

The next class of cases of chronic albuminuria, in which the 
kidney is structurally affected, are of a very different character. In 
these the kidney gradually diminishes in size, while its structure 
becomes very firm and dense {See p. 67). This form of renal 
disease has been termed gouty kidney, chronic nephritis, contracted 
kidney. The disease is closely allied to cirrhosis of the liver, and, 
like it, consists of a gradual contraction and condensation of the 
secreting structure. At first there is in both maladies engorgement 
of the vessels, and, consequent enlargement of the organs; but this 
state is followed by a gradual wasting process. The disease com- 
mences in the cells, and the pathological changes observed in the 
organs after death are the consequence of changes occurring in the 
cells. The cells become smaller, and the functional activity of many 
gradually ceases; the vessels waste, and at last the organ seems 
to be mainly composed of " connective tissue." I have shown that 
in fact, the so called "connective tissue corpuscles'' represent 
portions of wasted uriniferous tubes and cells. This contraction 
depends not upon inflammation and change occurring in effused 
lymph, but upon the wasting and condensation of the normal struc- 
ture. This form of renal disease results most commonly from drink; 
but I have seen small puckered and contracted kidney in persons who 
have never indulged in alcoholic liquors at any period of their life. 
The same observations apply equally to cirrhosis of the liver. 

In contracted kidney, the quantity of albumen in the urine is 
often so very small as to be sometimes overlooked. If the nature 
of the change which is occurring in the kidney be borne in mind, 



OF ALBUMIKURU. 209 

the practitioner will at once adopt the appropriate treatment : — diet 
that tasks the kidney as little as possible, and due attention to the 
general health. Tonics and iron are useful, but it must be admitted 
that in many of these cases we must give diuretics, and diurectics 
act most admirably sometimes. Compound decoction of broom, com- 
pound spirits of juniper and digitalis, and even cantharides may be 
given cautiously, and in some cases with great benefit. 

Treatment of albuminuria when the kidney is not affected. — 
Lastly, as to the treatment of those cases of albuminuria in which 
there is no renal disease. After exhausting haBmorrhages, in low 
conditions of the system, after low fevers, in some cases of phthisis 
and chronic bronchitis, and in some other conditions, albumen passes 
off in the urine. In some of these cases, dropsy is present, in others 
there is scarcely the slightest puffiness to be detected in any part of 
the body. Every effort must be made to improve the general health, 
and iron is especially valuable in these cases. I need scarcely say 
there is no indication for the use of remedies specially influencing 
the kidney. 

It is unnecessary to allude to the treatment of cases depending 
upon temporary internal congestion, as occurs in pneumonia and 
cholera, nor to those in which the escape of albumen depends upon 
pressure, exerted by the gravid uterus, or by internal tumors upon 
the veins. 

There are some other cases of albuminuria which have not been 
alluded to, as for example, cases of chylous urine, and cases of 
temporary congestion of the kidney, but these will be discussed in 
the proper place. For further and more detailed information, the 
reader is referred to the works of Dr. Johnson, and Dr. Basham. 

Bile. 

When much bile is present in urine, it gives to the secretion a 
very dark yellow colour, which is even more distinct when thin 
layers are placed upon a perfectly white surface, as on a plate, than 
where a considerable bulk of urine is examined. This arises from 
the presence of the colouring matter, which has received the name 
of hiliverdin. It may be completely removed from any solution 
containing bile by causing it to filter through a layer of charcoal. 
The presence of bile in urine is commonly observed in cases of 



210 ON DETECTING BILE 

jaundice. From some cause or other, as from pressure upon, or 
obstruction of, the common duct, bile, after it has been secreted, is 
partly or entirely prevented from escaping into the intestine. The 
gall-bladder and large and small ducts soon become distended by 
the accumulation of the secreted bOe, which, finding no escape, is 
reabsorbed. Some of its constituents pass into the blood, and are 
partly deposited in the tissues and partly carried off in the urine. 
That scarcely any bile passes into the intestine in many cases of 
jaundice, is proved by the pale colour, offensive odour, and clay-like 
consistence of the faeces. 

Several tests have been proposed for the detection of bile in 
urine. The efficacy of some of these tests depends upon a change 
being produced in the colouring matter; that of others upon 
alterations of the resinous acids. 



Fob DBTECTnra the CoLOUBiNa Matteb or the Bile. 

268. The Nitric Aoid Test.— This may be applied in two ways : 
(a.) A few drops of the biliary urine are to be poured upon a white 
plate, and a drop of nitric acid allowed to fall upon it. As the acid 
gradually mixes with the surrounding fluid, a play of colours, com- 
mencing in green, passing through various shades, and terminating 
in red, will be observed. 

(b,) A portion of the urine is to be placed in a test-tube, and 
treated as before. If much bile be present, a bluish-green colour at 
first appears. This is succeeded by various shades, until the play of 
colours terminates in red. 

259. Heller's Test consists in adding to the suspected urine a 
few drops of a solution of albumen, and, after agitation, a little nitric 
acid. If the colouring matter of bile is present, the flocculi of albu- 
men which are precipitated will possess a dull green or bluish 
colour. 

Not unfrequently, the albuminous flocculi, when thrown down 
by nitric acid in urine destitute of bile, are more or less coloured in 
consequence of the action of the nitric acid on the colouring matter 
of the urine (uroxanthine). The colour is sometimes reddish, 
sometimes bluish. This change is not unfrequently observed 



IN THE URINE. 211 

in albuminous urine ; and Dr. Basham considers it a condition of 
very unfavourable significance, and states that he has met with it 
most frequently in the acute forms of renal disease ("On Dropsy 
connected with Disease of the Kidneys,^ p. 48). This reaction must 
not be mistaken for that dependent upon biliary colouring matter. 

260. Colour of Phosphates. — After exposing urine to the air 
for a day or two, crystals of triple phosphate are formed, as is well 
known. If bile pigment be present, these crystals have a yellow 
tinge. Hassall ("The Unne;' p. 27.) 

261. Acetate of Lead.— In urine containing bile, the precipitate 
produced by the addition of acetate of lead has a yellowish colour. 

262. Evidenoe of Bile obtained by Microscopical Examination 
of the Deposit.— If the urine contain any epithelial cells from the 
kidney, as is usually the case, microscopical examination of the 
deposit will at once show the presence of bile, as the cells have a 
bright yellow tinge. The existence of this tinge proves conclusively 
the presence of bile colouring matter; but its absence cannot be 
regarded as satisfactory proof of the urine being free from bile. In 
cases of kidney disease, when bile is present in the urine, the casts, 
as well as the cells they contain, when examined in the microscope, 
are seen to have a deep yellow tinge. Cells of vaginal and bladder 
epithelium even, are often intensely coloured in cases of jaundice. 
In one case of jaundice, associated with wasting of the liver, I found 
a vast number of dumb-bells of oxalate of lime in the urine. These 
dumb-bells were coloured of an intense yellow colour, but the octo- 
hedral crystals, which were also present in considerable number, were 
colourless. 

The five tests just described enable us to detect only the 
colouring matter of the bile. 

Fob Detecting the Biliakt Acids. 

263. Fettenkofer's Test. — If albumen be present, this must 
first be coagulated, and separated by filtration. About a drachm of 
the urine is to be treated with about two-thirds of its bulk of strong 
sulphuric acid, which is free from sulphurous acid, the acid being 
added drop by drop, to prevent the temperature rising much above 



212 pettenkofeb's test for bile. 

100®; a piece of sugar, about the size of a large pin's head, or a drop 
or two of syrap may now be added to the mixture, and in the course 
of a minute or two a violet tinge will occur if bile be present. This 
test is not perfectly satisfactory, since it is very easy to obtain a 
reddish colour by the action of the acid upon the sugar if albumen 
and no bile is present ; moreover, oil of turpentine, oil of lemons, 
and of cloves, with other substances, yield similar results. In all 
these cases, however, the colour is not bright like that produced by 
the acids of the bile. The action of the sulphuric acid on the sugar 
alone produces a brownish-red, but this cannot be mistaken, as the 
colour is very different from that developed by bile. I recommend 
everyone to become familiar with these colours, by going through 
the experiments for himself by daylight with a diluted solution 
of bile. 

264.— Hoppe's Method.— The method of applying this test has 
been modified by Dr. Felix Hoppe, whose plan answers exceedingly 
well, and is so delicate that the smallest quantity of biliary acid can 
be detected with the greatest certainty. The urine suspected to 
contain bile is to be treated with excess of milk of lime, and boiled 
for half an hour. The clear fluid obtained by filtration is evaporated 
nearly to dryness, and then decomposed with excess of strong hydro- 
chloric acid. The mixture is to be kept boiling for half an hour, 
and the acid is to be removed from time to time, to prevent the 
spurting which would occur if the mixture became too concentrated. 
When completely cold, the mixture is to be diluted with from six to 
eight times its volume of water. The turbid solution is to be thrown 
on a filter, and the resinous mass washed until the water runs 
through quite colourless. The insoluble mass is next to be dissolved 
in spirit containing 90 per cent, of real alcohol, decolourised with 
animal charcoal, again filtered, and evaporated to dryness over a 
water-bath. The yellowish resinous residue is pure choloidic add. 
By warming it, it emits a peculiar musk-like odour. It is to be dis- 
solved m a little caustic soda and warm water, a little sugar added, 
and three drops of concentrated sulphuric acid are allowed to fall 
slowly into the mixture. The resinous acid is at first precipitated ; 
but afterwards, the flakes adhering to the glass are slowly dissolved 
by the addition of more sulphuric acid, and a perfectly clear fluid, 
of a beautiful dark violet colour, is produced. (Virchow's ^^ Archie,,'' 



CLINICAL IMPORTANCE OF BILE IN THE URINE. 21^ 

Vol. XIII. ; ^^ Archives of Medicine^^ Vol. I., p. 346 ; Abstract of 
Kiihne's Paper on '^ Icterus,'^ by Dr. 6. Scott.) 

265. On the Clinical Importance of Bile in the XTrine. — 

The consideration of this question involves the discussion of the 
pathology of jaundice, a subject upon which there is the greatest 
diflference of opinion in the present day. Indeed, observers are not 
even agreed as to the mere structure of the healthy organ; and 
Henle has very recently written a paper confirmatory of the view of 
Dr. Handfield Jones, who maintains that the liver-cells are situated 
outside the ducts, and are concerned rather with the formation 
of amyloid matter or sugar, than with the production of bile. 
Frerichs again in his work on diseases of the liver does not discuss 
the structure of the healthy organ, but seems to consider that the 
liver-cells lie between the capillaries in connective tissue, and have 
no direct connection with the ducts. In his numerous drawings he 
has almost ignored the existence of the ducts. He has described 
and figured in cirrhosis as " bindegewebe " (connective tissue), 
cell-containing-tubes as distinct, in properly prepared specimens, as 
any uriniferous tubes, and has omitted to represent the relation of 
the cells to the ducts in one single instance. Until these simple 
questions of elementary anatomy be decided, it is impossible that 
We can agree in opinion upon the altered action of so elaborate an 
organ as the liver in disease. Professor Frerichs' injections have been 
made with opaque injection, a mode of preparation which renders 
the demonstration of the healthy structure, or of the changes which 
have occurred in disease, impossible. 

I possess many specimens of the liver injected with transparent 
fluid (" Arehivesy' Vol. I.), which prove most conclusively, that the 
liver-cells lie in tubes continuous with the ducts. This view has now 
been received by Kolliker and others. The bile formed by the cells 
passes directly into the ducts, and is carried away by the larger 
ducts. In jaundice there are impediments to its escape from the 
large ducts outside the liver, or from smaller ducts within the 
organ. In either case the bile accumulates, the ducts become 
stretched, a certain quantity passes through their coats, and is taken 
up by the bloodvessels, or what is more probable, is absorbed by the 
numerous lymphatic vessels, ramifying in the portal canals, and 
in the transverse fissure of the liver. 



214 CLINICAL IMPORTANCE 

It is, however, held by Dr. Budd, that jaundice may result — 
1. From obstruction to the escape of bile from the liver after it has 
been formed, and, — 2. From what is termed suppressed secretion, in 
which case it is supposed that the substances, which should be 
separated from the blood and converted into bile, remain in the 
drcolation. Frerichs, Eiihne, and others, have brought forward 
aigoments opposed to this view, but it has recently received support 
from the observations of Dr. Harley, who observes that certain con- 
stituents (biliverdin, cholesterine) of the bile, are produced in the 
blood, and are only separated, and not formedy by the liver, while 
there are other constituents (glychocholic and taurocholic acids) 
which are actually formed by the liver. From this he argues, that 
where the colouring matter is alone found in the urine, the case is 
one of jaundice from suppression, while, if the biliary acids are 
present, it is clear that these substances must have been formed 
by the liver, reabsorbed into the blood, and excreted in the urine, 
and the case, therefore, arises from obstruction. 

It must, however, be borne in mind that the proportion of 
biliverdin and cholesterine in bile is very small, and that although 
biliverdin can be formed from the colouring matter of the red 
blood corpuscles, and might tinge the tissues and the urine, no one 
has shown that it is ever produced in sufficient quantity to give rise 
to the intense general staining often seen in jaundice. There are 
fsucts in favour of the view that colouring matters as well as the 
resinous acids are actually formed in the liver. Moreover, it is 
difficult to conceive, that a large and important organ like the liver, 
can cease to perform its functions for three weeks or a month, 
without giving rise to the most serious constitutional symptoms, and 
without itself suflfering most serious alterations in structure. Nor 
have those who support the suppression theory attempted to explain 
what becomes of the large quantity of material, which would, under 
other circumstances, have undergone conversion into biliary acids. 

On the other hand, in certain cases of cirrhosis, where there is a 
most positive and gradual wasting of the secreting structure of the 
liver, there is no jaundice. How is it that the biliverdin, formed in the 
blood, does not tinge the tissues in these cases 1 Nor are we justified 
in placing the same reliance upon Pettenkoffer's test when applied 
to the urine, as some observers are inclined to do. I cannot feel 
satisfied that in those cases in which I fail to obtain indications of 



OF BILE m THE UBINE. 215 

the resinous acids, that they are reaUy absent. Euhne has detected 
the presence of bile acids in many specimens of icteric urine, by 
following Dr. Felix Hoppe's method (§ 264). Although all recent 
observers, who have studied this subject, admit that the detection of 
the biliary acids is most difficult and requires the greatest care, 
Dr. Harley seems to rely upon the ordinary Pettenkofer's test to 
distinguish two classes of cases of jaundice. Kuhne's observations 
have quite disproved Frerichs' theory, that the biliary acids were 
converted into bile-colouring matters in the blood, and the statement 
of Frerichs and Stadeler, that bile-colouring matter and bile acids 
never appear together in the urine, has been shown to be erroneous. 
For full information upon this subject the reader is referred to an 
abstract of Kuhne's observations by Dr. Scott. ("-4rcAtw«," VoL 
I., p. 342.) 

It seems to me that the view that in certain cases of jaundice 
there is suppression of the action of the liver, that the liver does not 
produce bile, and that no biliary acids are formed, is opposed to very 
many facts, and I have been led to incline towards the view that in 
all cases of jaundice the bile has been formed by the liver cells, and 
has been reabsorbed after its formation, and perhaps much of it again 
excreted in an altered form by the intestines. It is easy to conceive 
that the relative proportion of the biliary acids and colouring 
matters produced, may be very different in different cases — that the 
quantity of the acids formed, may vary greatly — ^that their com- 
position may be affected — taurocholic acid being produced instead of 
glycocholic acid (KUhne) — ^that the quantity of blood corpuscles 
disintegrated by the presence of bile compounds in the blood — and 
that other chemical derangements may be caused without the action 
of the liver cells being suspended. 

266. On the Treatment of Cases of Janndioe. — Cases of 
jaundice, which occur so commonly during the summer months, and 
are not connected with organic disease, require but very simple 
treatment. The jaundice usually lasts for a period varying from a 
fortnight to five or six weeks, and then gradually disappears. The 
pathology of these common cases is not at all understood. In many 
there is scarcely any constitutional disturbance, although the urine 
is very dark-coloured and sometimes contains biliary acids, and the 
foBces are perfectly colourless. Gentle laxatives and small doses of 



216 TBBATMEMT OF JAUNDICE. 

hydrochloric acid or ammoniacal salts seem to do good, bat the 
remedial measure in which I have the greatest confidence consists 
in mild counter-irritation over the liver. Even the application of 
cold wet cloths for half an hour now and then will relieve the 
pain, sense of fulness, or uneasiness, about the hepatic region ; but 
rags steeped in equal parts of strong hydrochloric acid and water 
applied for half an hour dally form the best application. This appli- 
cation, which I learned from Dr. Blakiston, is of great service, not 
only in actual jaundice, but in cases of temporary biliary derange- 
ment generally. The acid may, perhaps, act through the cutaneous 
nerves, by exciting the biliary ducts and gall bladder to contract 
It also causes action of the colon. Small doses of mercury once a 
week seem to give relief in some of these cases. Muriate of 
ammonia (20 grains three times a day) and benzoic acid (3 to 6 
grains three times a day) are favourite remedies on the continent. 
In health, benzoic add is excreted in the urine in the form of 
hippuric acid ; but in jaundice Euhne has shown that benzoic acid 
and benzoates pass unchanged into the urine. I have given podo- 
phyllin (J grain every other day) in several cases, but can offer no 
opinion as to the advantages of the remedy. In some cases inspis- 
sated bile appears to do good. Dr. Harley has had it prepared by 
Messrs. Savory and Moore, enclosed in gelatine capsules — a very 
useful suggestion, as the bile is not set free until it reaches the 
duodenum. 

In cases of jaundice depending upon permanent closure of the 
duct, as from pressure of a tumour, impaction of a gall stone, &c., 
the jaundice continues, and bile passes off in the urine as long as the 
liver retains the power of secreting it. I shall not enter into the 
consideration of the treatment of those terrible cases in which the 
jaundice depends upon acute wasting of the liver, or upon the rapid 
disorganisation which sometimes follows a severe blow. The greatest 
caution should always be exercised in giving an opinion as to the 
cause of jaundice, and also as regards the prognosis. For further 
information upon the subject of jaundice, the reader is referred to 
the works of Dr. Budd "On the Livery'' Dr. Harley "Ow Jaundice,'" 
and Dr. Thudichum "On GaU Stones," 



217 



CHAPTER XII. 



Urine in Disease. Soluble Substances which do not exist 
IN THE Healthy Secretion — Sugar, Alcapton, Leucine, 
Trtosine, Inosite, Acetone, Cystine. Sugar in Healthy 
Urine— ^Diabetes — General Characters of the Urine in Dia- 
betes — Colour — Smell — Of the Urea and other Constituents — 
Albumen in Diabetic Urine — Specific Gravity — Reaction — 
Deposits — Diabetic Sugar^ or Glucose — Tests for Diabetic 
Sugar — Moore^s Test—Trommer^s Test — BarreswiVs and 
. other Solutions — Circumstances interfering with the Action 
of Trommerh Test — On Testing for Sugar when only Traces 
are present — Brilcke^s Test for Traoes of Sugar — Of the 
Yeast Test — Maumeni^s^ or the Perchhride of Tin lest — 
Bismuth Test — Chromate of Potash Test — Of Estimating 
the Quantity of Sugar — Volumetrically — Fermentation — 
Dr, Garrodh Method — The Polarising Saccharimeter — 
Dr, Roberts^ Plan — Observations upon the Nature and 
Treatment of Diabetes — Amyloid of Glucogenic Matter — 
Bernard^ s Researches — Views of Dr. Pavy and Dr. Harley — 
On the Formation of Amyloid^ Fat^ Sfc, in the lAver^cell — 
Dr, Mc DonnelVs Observations — Of the Clinical Importance 
of Sugar in the Urine — Cataract in Diabetes — Origin of the 
Urea in Diabetes — Sugar in the Urine in Disease of the 
Respiratory Organs — The Experiments of Reynoso and 
Dichambre repeated — Analyses of Urine in Diabetes — On 
THE Treatment of Diabetes — Substitutes for Bread — Diet — 
Wines — Pepsin — Medicine — Alcapton, Leucine, Tyrosine, 
Inosite, Acetone, Cystine. 

267. Sugrar in Healthy TJrine. — Traces of sugar are stated to be 
present in healthy urine, by Briicke, whose observations have been 
confirmed by Dr. Bence Jones. The proportion is, however, not suf- 
ficient to be recognised by the ordinary tests, unless some of the 



218 DIABETES. 

other urinary constitaents are first separated. It is possible that 
the colouring matter in healthy urine may be the source from which 
the small quantity of sugar present is derived. Schunk has 
shown that the substance from which indigo is obtained exists in 
the plant as a body he terms indican. This indican, when heated 
with strong acids, splits up into indigo blue, indigo red, and a kind 
of sugar (CuHioO ). My friend Professor Bloxam has shown that 
specimens of urine which give no indications of the presence of sugar 
(copper test), when heated with sulphuric or hydrochloric acid, 
deposited a brown precipitate of the same composition as anthranilic 
acid (CiiHTNOi), a product of the decomposition of indigo blue. 
These deposits being separated by filtration, it was found that the 
clear fluid gave decided indications of sugar, (Bowman's " Medical 
Chemistry,^' fourth edition, p. 15.) 

Occasionally traces of this substance may be detected in the urine 
of persons who are not suffering from any particular symptoms. It 
may be excreted for days, or even for a few weeks at a time, in small 
proportion. These cases do not generally pass into confirmed diabetes, 
but they should be carefully watched by the practitioner. Some- 
times, after abstinence from food for some hours, a meal, consisting 
entirely of starchy matter, will cause sugar to appear in the urine, 
and if a person, under these circumstances, take a quantity of cane 
sugar, a temporary diabetic condition will almost certainly be 
induced. 

Diabetes. 

268. Diabetes.— Although sugar may have been detected in the 
urine daily for several weeks, recovery often takes place. Diabetes 
may last for many years, but it frequently causes death in from one 
to four years. Although much light has been thrown upon the pro- 
duction of sugar in the animal body of late, no satisfactory explana- 
tion of these cases has yet been offered, nor do we know anything of 
the condition of the system which precedes and ushers in the fatal 
form of diabetes. 

Two kinds of diabetes have been described — diabetes meUitus and 
daibetes insipidus, I have already had occasion to allude to the 
latter (§ 195), and have mentioned that in this condition large 
quantities of pale urine, containing little solid matter, and, it need 
scarcely be repeated, no sugar, are passed, it is therefore quite 



URINE m DIABETES. 219 

unnecessary to describe this condition as a distinct disease; the term 
diabetes should never be applied to it. Diabetes is sometimes called 
mellituria or glucosuria, 

269. General Characters of Diabetic Urine: Colour: SmelL — 
Diabetic urine usually possesses a peculiar smell, which has been 
compared to that of violets, apples, new hay, whey, horses' urine, 
musk, and sour milk. Such comparisons, serve only to show how 
difficult it is to give by description a correct idea of a particular odour. 
The colour of diabetic urine is generally pale. Sometimes, but not 
usually until after two or three days, the surface becomes covered with 
a whitish film, owing to the development of the Sugar fungus and 
Penicilium glaucum. It has a sweet taste, and often attracts a 
great number of flies. This is sometimes the first thing which 
directs the attention of the patient to his urine. Diabetic sugar 
sometimes disappears from the urine, and Inosite^ a substance 
nearly allied to sugar, but obtained normally from muscles, takes 
its place. 

270. Of the Urea and other Constituents.— The quantity of urea 
varies greatly in different cases of diabetes. In advanced cases it is 
diminished, but a considerable excess is often excreted. In one 
case reported by Prof. Sydney Kinger, that of a woman weighing 
104 lbs., 764 grains of urea were excreted in 24 hours, which corre- 
sponds to 7 grains per pound of the body weight, the quantity in 
health being only 3*5 for each pound weight of the body. In one of 
Dr. Garrod's cases as much as 1085 grains of urea and 3,500 grains 
of sugar were eliminated in 24 hours. 

The observation of Lehmann, that diabetic urine invariably con- 
tains hippuric acid and never uric acid is undoubtedly erroneous. In 
this country, at least, it is not uncommon to meet with an abundant 
deposit of uric acid. Dr. Prout regarded the presence of uric 
acid as a favourable sign. The cases in which I have observed it 
have not been very severe cases. In several I have seen an 
abundant deposit of uric acid. Hippuric acid is said to be present 
in diabetic urine (Lehmann and others) ; but in some specimens of 
urine, in which Dr. Garrod sought for it, he failed to detect it. (Gul- 
stonian lectures, " Brit Med, Jour.,'^ 1857.) I have detected it 

Sulphocyanogen has been detected in diabetic urine by Schultze. 
Perchloride of iron strikes a red colour if solphocyanides be present. 

l3 



220 PRESENCE OF ALBUMEN 

Heller states that the uroxanthin is increased, and Schunk obtained 
much indigo from diabetic urine. A reddish tint is often produced 
by the addition of nitric acid, but this is often observed in various 
specimens of urine which do not contain sugar. 

271. Albumen is sometimes present in diabetic urine. Garrod 
detected it in ten per cent, of the cases. Dupuytren and Thdnard 
considered it a &vourable symptom. Rayer, on the other hand, 
considers it arises from renal disease. In a case which I saw lately, 
the only symptoms were dyspepsia and the secretion of rather a 
large quantity of urine (3 pints). Diabetes was not suspected. I 
examined the urine, and found an abundant precipitate of albumen, 
with a large quantity of sugar. I expressed a very unfavourable 
opinion as to the result, although emaciation had scarcely com- 
menced. The patient died about six months after I had seen him. 
Albumen was detected during six months, and may have been 
present at an earlier period of the case. The first specimen of urine 
was of specific gravity 1028, and contained albumen and sugar. 
The former was not estimated. 

Analysis 48. 

Water 922-00 

Solid matter 78*00 

Urea 12-00 

Sugar 3800 

Fixed salts 10*60 

A specimen examined a month afterwards, the diet having been 
properly restricted, had a specific gravity of 1023, and was high 
coloured. 

Analysis 49. 

Water 936*80 

Solid matter 63*20 

Urea 8*16 

Sugar 46*15 

Albumen 2*21 

Fixed Salts 1*40 

Dr. Gibb found albumen in the urine in the pelvis of one kidney, 
and sugar in that present in the other in a case of death from cancer 



m DIABETIC URINE. 221 

of the liver. The urine containing albumen had a specific gravity 
of 1015, and that containing sugar a specific gravity of 1026. 

Albumen should always be sought for in diabetic urine ; and it 
should be borne in mind that its presence interferes with the 
reaction of the copper test (§ 277). 

272. Speoific Gravity— Beaction— Deposits. The specific 
gravity of diabetic urine is very high, almost always above 1030, and 
it sometimes reaches 1050. In some cases, however, the specific 
gravity does not differ from the healthy standard, and may be as low 
as 1010. This fact shows that we must not conclude that sugar is 
necessarily absent in urine of low specific gravity. Its reaction is 
generally acid, sometimes excessively so. 

Deposits are not often met with in diabetic urine; those which 
have come most frequently under my own notice are deposits of 
the phosphates, and deposits of uric add. The fixed salts are 
generally present in small quantity, and chloride of sodium is often 
altogether absent. The extractive matters are, as a general rule, 
relatively much diminished in quantity; but in some cases they 
exist in considerable proportion. 

273. The Quantity of urine secreted by patients suffering from 
this malady is sometimes enormous, and in many cases this is the 
first point to attract attention to the disease. Some patients have 
passed as much as twenty pints of urine per diem, and P. Frank 
mentions a case in which the enormous quantity of fifty-two pounds 
was discharged in twenty-four hours. The proportion of solid 
matter passed in twenty-four hours varies greatly in different cases; 
it not unfrequently exceeds two pounds, the greater part of which 
is composed of sugar. 

274. Diabetic Su^ar is easily obtained from the urine when but 
little urea and extractive matter are present. That particular form 
of grape sugar or glucose which is obtained from diabeted urine 
differs both from the sugars of fruits, and also, in some particulars, 
from the sugar obtained from the liver. It generally appears as a 
treacle-like mass, but of a pale brown colour, which does not crys- 
tallize, especially if heat be employed in evaporating the solution. 
I^ however, some of the urine of specific gravity 1050, from a bad 
case, be allowed to evaporate at a temperature of 100°, small warty 



222 DIABETIC SUGAR. 

masses, of a rounded form, soon make their appearance. Under the 
microscope, these are seen to have projecting from the surface very 
beautiful crystalline plates. When a considerable quantity of the 
sugar has crystallized, it may be washed with ice-cold water, well 
pressed between folds of bibulous paper, and dried over sulphuric 
acid. It is now in many cases, neariy colouriess, and, after two or 
three crystallizations, from distilled water, it becomes nearly pure. 
In Plate XIII., Fig. 66, some beautiful crystals of grape-sugar are 
represented. These were obtained by allowing a few drops of 
diabetic urine, containing a mere trace of urea and salts, to evaporate 
spontaneowly on a glass slide. Similar crystals were obtained from 
the tears of the patient (case reported by Dr. Gibb, in " Archives of 
Medicine,^^ Vol. I., p. 250). I have obtained crystals from several 
specimens of diabetic urine. These crystals are very beautiful 
objects when examined by polarised light. When burned they leave 
scarcely a trace of residue. It is curious that crystals of diabetic 
sugar have not been figured before. 

275. Of the TomlsD developed in Dial}etic Urine.— There are 
two kinds of fiingi which are developed in diabetic urine — the yeast 
ftingus, and the penicilium glaucum. The former is characteristic 
of saccharine urine, and Dr. Hassall considers the development of this 
fungus a most valuable test. (" The Urine in Health and Diseasei*^ 
p. 146, Figs. 43, 44.) It is necessary, however, to set the urine aside 
for a few days, before the ftingus will form, so that it is inapplicable 
as a test if we desire to determine within twenty-four hours if the 
suspected urine contains sugar. In many cases, no fungus whatever 
is to be found, even in two days. Moreover, the young sporules of 
the sugar ftingus cannot be distinguished from those of penicilium 
glaucum. The microscopic characters of these fungi will be 
described under the head of Urinary Deposits (Chapter XV ). 

Tests fob Diabetic Sugab. 

The presence of grape sugar in urine is readily ascertained by 
the application of certain tests, and if moderate care be taken in the 
examination, the detection of this substance is not open to many 
fallacies, unless mere traces are present, in which case see §§ 280, 
281. 



DIABETIC SUGAR AND APPARATUS. Platb XIII. 



Fig. 66. 








%^\ 



Fig. 66*. 




§274 



§ § 276, 350 



irig.67. 



Fi6f.6S. 




To .foxft v>^«%'«.*l- 



Moore's test. 223 

276. Moore's Test for grape sugar consists in adding, to the 
urine suspected to contain it, about half its bulk of liquor potassae. 
If sugar be present, the mixture becomes of a rich brown colour 
upon boiling, which increases in intensity if the boiling be prolonged. 
The brown colour of the solution is owing to the formation of 
mellassic or sacchulmic acid; glucic acid is also produced in the 
decomposition. This test, however, cannot be depended upon for 
detecting the presence of small quantities of sugar, because there 
are some other substances besides sugar which will cause the 
development of the colour in a slight degree. If excess of nitric 
acid be added, a strong treacle-like odour results, and the solution 
becomes pale. 

277. Trommer's Test.— Of all the tests which have yet been 
proposed, that originally suggested by Trommer, or some slight 
modification of it, will be found of the greatest practical value for 
showing the presence of sugar in diabetic urine, in clinical inves- 
tigations. Trommer's test is applied as follows: — A small quantity 
of the urine is poured into a test tube, a drop or two of a solution of 
sulphate of copper is to be added, and about half as much liquor 
potassae as there is of urine. If sugar be present in any quantity, 
the precipitate at first formed will be redissolved, and the solution 
will be of a dark blue colour. If only traces of sugar are suspected 
to be present, one drop of the sulphate of copper solution will be 
sufficient. The dark blue solution is now to be heated to the boiling 
point, and if sugar be present, a pale reddish brown precipitate of 
suboxide of copper is immediately thrown down. Instead of boiling 
the mixture, it may be allowed to stand for some time, when a 
similar deposit will gradually subside. If the suboxide is only 
reduced after prolonged boiling, this cannot be taken as good evidence 
of the presence of sugar, for under these circumstances there are some 
other substances which will cause the reduction of the oxide of 
copper. Again if the solution simply change colour by boiling, 
without the occurrence of a distinct precipitate or the production of 
an opalescence, we must not infer that the change is necessarily due 
to the presence of sugar, for almost all specimens of urine exhibit 
this change. A flocculent precipitate of earthy phosphate, which 
always takes place, cannot be mistaken for the suboxide, as it is 
quite colourless, or of a pale greenish tinge. The reaction alone 



224 tbommer's test 

characteristic, is the production of a brown or yellowish precipitate 
(varying in quantity according to the amount of sugar the urine 
contains), either after the mixture has stood for some time, or upon 
boiling it not longer than for a minute. 

If albumen be present, the reduction of the oxide of copper does 
not take place, so that in using the copper test we must ascertain 
that this substance is absent. Albumen may be removed by pre- 
cipitation by heat and acid and subsequent filtration, the free acid 
being neutralised with potash or soda, but not by ammonia, before 
the application of the test; or the albumen may be separated by 
sulphate of soda (§ 282). Ammonia dissolves suboxide of copper. 
It has been shown that leucine, allantoin, creatine and creatinine, 
cellulose, tannin, and chloroform, have the power of producing a pre- 
cipitate of suboxide of copper, like grape-sugar, and more recently, 
M. Berlin has proved that uric acid possesses to some extent the same 
property. 

278. Modifications of Trommer's Test have been proposed by 
Barreswil, and others, the most applicable, however, according 
to Lehmann, being that of Fehling. (Lehmann's " Physiological 
Chemistry, ^^ by Day, Vol. I., p. 288. Cavendish Society.) The action 
of these test solutions is the same, and depends upon the following 
circumstances: — The protoxide of copper is not dissolved by an 
alkali alone; but, if certain organic matters be present, complete 
solution Occurs. Tartaric acid and bitartrate of potash do not cause 
the reduction of the suboxide at the temperature of ebullition, and 
these are the salts usually employed. If grape sugar be present, 
however, the protoxide is reduced to the state of suboxide of copper 
when the mixture is boiled. The composition of Barreswil's solution, 
which was used by Bernard in his experiments, is given below. 
These tests are more easily applied than the sulphate of copper and 
potash. I shall, therefore, give the composition of some of the best 
solutions — Fehling's solution is made as follows: — 69 grains of 
sulphate of copper are to be dissolved in 345 grains of distilled 
water; to this solution a concentrated solution of 268 grains of 
tartrate of potash, and then a solution composed of 80 grains of 
carbonate of soda in an ounce of distilled water are to be added; the 
mixture may be poured into a 1,000 grain measure, and filled up 
with water. 



Ain> ITS MODIFICATIONS. 225 

Barreswil's solution is composed of the following constituents: — 

Cream of tartar 96 grains. 

Crystallised carbonate of soda . , . 96 », 

Sulphate of copper 32 ^ 

Caustic potash 64 ,, 

Water 2 fluid ounces. 

Dr. Pavy recommends the following modification of Fehling's 
solution. Half a grain of sugar exactly reduces the oxide contained 
in 100 minims of the solution. 

Sulphate of copper 320 grains. 

Tartrate of potash (neutral) . . . 640 „ 

Caustic potash (potassa/usa) . . . 1,280 „ 

Distilled water 20 fluid ounces. 

The tartrate of potash and caustic potash are to be dissolved 
together in one portion of the water, and the sulphate of copper 
alone in the other. The two solutions are then mixed. (" On 
Diabetes.") 

In using these tests, it is only necessary to add about an equal 
bulk to the urine in a test tube, and then to boil the mixture. If 
sugar be present, the precipitate of suboxide occurs immediately. 
The application of this solution to the quantitative determination of 
sugar has been considered under volumetric analysis (§ 47). 

Trommer's, or one of the above mentioned modifications, will be 
found the most delicate test which can be used, when only small 
quantities of sugar are suspected to be present, and the tartrate of 
copper solution is applied as easily as the liquor potassae test, while 
the results obtained from it are far more to be depended upon. The 
tartrate solutions become decomposed by the action of the light, and 
some suboxide is deposited. In this case, its strength is of course 
impaired. It will also, after having been kept for some time, deposit 
suboxide, when boiled by itself; in which case a little fresh potash 
should be added. 

279. CiroxixnstazLces interferiner with the action of Tzommer^s 
Test.— Some years since I endeavoured to ascertain the cause of 
certain anomalous results, which were occasionally met with in em- 
ploying the test; and as these to some extent explain the discrepan- 
cies of different authorities with reference to the presence or absence 

L 5 



226 DISCREPANCIES IN THE 

of sugar in the urine in certain cases, it is well to allude to them 
here. The following results were ohtained : — 

1. The precipitate of suboxide of copper was readily dissolved by 
acetic, hydrochloric and nitric acids. It was also dissolved by am- 
monia. 

2. The precipitate was insoluble in a solution of chloride of 
sodium, but was readily dissolved by a weak solution of chloride of 
ammonium. 

3. The addition of a few drops of chloride of ammonium previous 
to boiling entirely prevented the precipitation of the suboxide, the 
mixture retaining its greenish colour. Upon adding some solution 
of potash, however, the precipitate of suboxide was produced, and 
ammoniacal fumes were given oflf at the same time. If a moderate 
quantity of solution of chloride of ammonium was present, the pre- 
cipitate did not occur upon the addition of potash, even after very 
prolonged boiling. 

4. If a drop of a very dilute solution of the chloride of ammo- 
nium was added to a pretty strong solution of sugar, and, after the 
addition of the tartrate, the mixture was boiled, no precipitate took 
place, but the solution became of a pale brown tint ; the suboxide 
being immediately thrown down upon the addition of a few drops of 
a solution of potash, with the development of ammoniacal fames. In 
the above cases in which no precipitate took place, it was ascertained 
that there was the usual excess of alkali present in the test solution. 

5. A solution of oxalate of ammonia also prevented the precipita- 
tion of the suboxide, but a greater quantity of this salt than of the 
chloride of ammonium was required. 

6. A neutral solution of urate of ammonia (artificially prepared) 
also prevented the reduction of the suboxide, and dissolved the pre- 
cipitate if added to it. On carrying out this experiment further, it 
was found that the precipitate of suboxide of copper was dissolved by 
urine containing an excess of urate of ammonia, 

7. A solution of grape-sugar in water was prepared, and by a 
preliminary experiment it was ascertained that, upon being boiled 
with the tartrate test, an abundant precipitation of suboxide took 
place. 

To a portion of the precipitate of suboxide produced in this way, 
about a drachm of healthy urine, immediately after it was passed, 
and while yet warm, was added, and the reddish precipitate was 



REACTION OF TROMMER's TEST. 227 

instantly dissolved, forming a perfectly clear solution. Upon fiirther 
boiling, a slight precipitate of phosphate took place. The suboxide, 
however, could not be precipitated by the further addition of potash 
and prolonged boiling. 

8. Upon mixing a small quantity of grape-sugar with the same 
specimen of healthy urine, and boiling the mixture with the tartrate 
test, no precipitate, except a little phosphate, was produced. About 
half an ounce of the same mixture of urine and grape sugar was 
placed in a test tube, mixed with six drops of yeast, and inverted 
over mercury. The whole was then placed in a temperature from 
70° to 100° for about twelve hours, at the end of which time the 
tube was found quite filled with gas, and all the liquid was expelled 
into the vessel in which it had been placed. The specimen of urine 
with which the above experiments were tried, was allowed to stand 
in a still place ; and when it had become quite cold, an abundant 
precipitate of urate of ammonia was found to be present. 

9. A portion of the aqueous solution of grape-sugar was mixed 
with a strong solution of urate of ammonia (artificially prepared), 
and then a certain quantity of the tartrate solution was added, and 
the mixture boiled. The characteristic precipitate, or opalescence, 
was not produced, but the mixture became of a pale fawn colour. 
In a weak solution of urate of ammonia, the characteristic precipitate 
appeared after boiling the mixture for some minutes. 

8o that, althotigh much sugar is present, the colour of the mix- 
ture may he merely changed to brown, and no precipitate whatever 
may take place, 

10. A solution of grape-sugar was treated with a drop of a dilute 
solution of chloride of ammonium, and boiled with the tartrate 
solution. The mixture became of a brown colour, but no precipitate 
occurred. Upon the addition of a few drops of solution of potash, 
the precipitate of suboxide was produced. 

A solution of grape-sugar, treated with Trommer's test, according 
to the usual method, behaved in the same way, in the presence of 
chloride of ammonium, as when treated with the tartrate of copper 
solution; but in this case a greater quantity of the chloride was 
necessary, for when only traces were present, ammoniacal vapours 
were given ofi^ and the precipitate of suboxide subsided, as before 
remarked. 

From the results of the above experiments, the following conclu- 



228 ON TESTING FOR TRACES 

sions with reference to the practical application of Trommer's test, 
and Fehling and Barreswil^s solutions, and other modifications of 
the copper test, may be drawn* : — 

1. That if the urine contain chloride of ammonium (even in very 
small quantity), urate of ammonia, or other ammoniacal salts, the 
suboxide of copper would not be precipitated if only a small quantity 
of sugar were present. 

2. That unless there be a considerable quantity of one of the 
above salts present (in which case the blue colour will remain), the 
mixture will change to a brownish hue upon boiling, but no opal- 
escence or precipitate of suboxide of copper will occur. When only 
a moderate amount of sugar is present, I have been unable to obtain 
a precipitate, under these circumstances, by the addition of potash 
to the solution, and prolonged boiling. By observation 8, it appears - 
that a specimen of urine exhibiting this reaction may contain a large 
quantity of sugar, as ascertained by the yeast test. 

3. That in many cases in which the precipitation of the sub- 
oxide is prevented by the presence of ammoniacal salts, the addition 
of potash to the solution, and subsequent boiling, will cause the 
production of a precipitate with the evolution of ammoniacal fumes. 
Hence, care should always be taken that there is a considerable 
excess of free alkali present. 

4. When only small quantities of sugar are present in the urine, 
and the precipitate of suboxide of copper is not decided, the fermen- 
tation test should be resorted to. 

Upon treating different specimens of diabetic urine with Trom- 
mer's test, or its modifications, it has often been noticed that in one 
case the precipitate is produced as soon as the mixture reaches the 
boiling point, or even before; while, in other instances, it is necessary 
to keep it in active ebullition for some minutes, before any precipitate 
is produced. This circumstance receives explanation from the facts 
above detailed with reference to the presence of ammoniacal salts; 
and other anomalous results, which must have occurred to many in 
the habit of employing this test, become explained. 

Specimens of urine in which sugar is suspected to be present, 
and no decided precipitate of suboxide (which must be carefully 

* Professor Briicke has recently drawn attention to the action of ammonia in pre- 
venting the precipitation of the suboxide of copper, and other points connected with 
this snbject Probably he had not seen the results just given, which were obtained in 
1852, and publLohcd in the - Med.-Chir. Review,'* Jan. 1863, Vol. XL, p. 113. 



OF DIABETIC SUGAR. 229 

distinguished from phosphate *) occurs, should be carefully fermented 
with yeast (§ 283) before any conclusion is arrived at. 

280. On Testing for Sugrar when only Traces are Present. — 

In fluids which are suspected to contain only mere traces of sugar, it 
is necessary to separate some of the other constituents before 
applying the test. The plan recommended by M. Leconte is the 
following: — Excess of acetate of lead is added, and the precipitate 
separated by filtration. The solution is concentrated by evaporation, 
treated with ammonia, and again filtered. The copper test is then 
applied. The objections to applying the reduction test to solutions 
containing ammonia has been already discussed. It is better to 
employ carbonate of potash, or soda, instead of ammonia. The excess 
of lead salt may also be removed from the filtered solution by passing 
sulphuretted hydrogen. * The precipitate of sulphuret of lead is 
removed by filtration, and the liquid, after evaporation to a small 
bulk, may be tested. 

Another plan recommended by M. Leconte is to treat the urine 
with acetic acid, and evaporate it to about the fifth of its bulk; it is 
then treated with alcohol, and after filtration from the salts, &c., the 
alcoholic solution is evaporated and tested. This plan is free from 
the objection that ammonia may cause the destruction of the sugar 
where only traces are present. 

281. Briicke's Test for Traces of Su^ar.— Neutral acetate of 
lead is first added to the urine and afterwards basic acetate of lead. 
The precipitate is to be separated by filtration, and ammonia added 
to the solution. The precipitate, by ammonia, is decomposed by 
oxalic acid, or suspended in water and sulphuretted hydrogen passed 
through it. The filtered solution contains the sugar, which may be 
detected by any of the tests already mentioned. By this process, the 
seventh of a grain of sugar may be detected, when diluted with 
upwards of six ounces of water, and two-thirds of the total quantity 
of sugar present in a solution can be separated by this process. 

282. Testing for Sufirar when much Albumen or allied 
Compounds are Present. — If such a mixture containing sugar, be 
boiled with about an equal weight of sulphate of soda in crystals, 

* The precipitate of suboxide may be diatinfiraished from phosphate by its solubility 
in amiuonix 



230 THE YEAST TEST 

the whole of the albuminous matters are separated, while the 
sulphate does not in any way interfere with the application of the 
sugar tests. By this process, the presence of sugar may be detected 
in blood or in the solid organs of the body. Bernard recommends 
animal charcoal for separating albumen, uric acid, casein, and fatty 
matters, from solutions which are suspected to contain sugar. The 
latter substance filters through the animal charcoal unchanged. 

288. The Teast Test. — This is one of the most satisfactory tests 
for the presence of sugar, and if tried with proper care can hardly 
fail in its results. Two test tubes, of the same form, and of equal size, 
are to be taken. One is nearly filled with water, and into the other 
a corresponding quantity of the urine is to be poured. An equal 
amount of yeast is now to be added to the liquids in the tubes, and 
after pouring in just sufficient fluid to fill the tubes, the thumb is to 
be carefully placed over the opening, and the tube inverted in a 
small cup of mercury. 

The plan which I have found most convenient is the following: — 
A little india-rubber pad, slightly larger than the upper extremity 
of the tube is to be cut out of a sheet of india-rubber. When the 
tubes have been filled up to the brim with a little water, the pad is 
allowed to float on the surface; next a little cup or beaker is 
inverted, and carefully placed over the end of the tube. The india- 
rubber being pressed against the open end, the fluid is prevented 
from escaping. The whole may be inverted, and a little mercury 
having been poured into the beaker, the india-rubber may be 
removed with forceps, without any escape of the fluid. The tubes 
may be supported in position by a wire stand. Both tubes are then 
to be exposed, for a few hours, to a temperature of from 80° to 90°, 
and the comparative size of the bubble of gas in the upper part of 
each may then be noted. If an appreciable quantity of sugar be 
present, the bubble of gas in the tube containing the urine will be 
many times larger than that in the tube which contains the yeast 
and water. In the latter tube the bubble of gas merely arises from 
the small quantities of air previously mixed with the yeast, becoming 
disengaged, and floating to the surface. Fermentation, when 
carefully performed, is positive evidence of the presence of sugar, 
although it does not indicate the kind of sugar present. 

The carbonic acid can be 'detected in the fermented liquid by 



FOR DIABETIC SUQAB. 231 

potash. A fragment of potash is placed in the tube, and the end 
immediately closed with the thumb. If carbonic acid be present, it 
is soon absorbed by the potash, and upon the closed end being placed 
under the surface of water, and the thumb removed, a quantity of 
water will rise in the tube equal to the volume of the carbonic add 
absorbed. 

The alcohol may be separated from the fermented liquid by 
distillation. After a few drops have passed over, they may be tested 
for alcohol, with the bichromate of potash test, as follows. The solu- 
tion suspected to contain the alcohol is poured into a test tube, and 
a little dilute sulphuric acid added. A drop of solution of bichrc^- 
mate of potash is added, and the mixture heated. If alcohol be 
present, the brownish colour changes to a bright emerald green. 

284. MatunenS's Test.— A little woollen rag, as merino, is cut 
into strips, and soaked for four or five minutes in a solution of per- 
chloride of tin (one part of the perchloride to two parts of water). 
The slips are then dried over the water bath. A drop of the urine 
suspected to contain sugar is allowed to fall on a small slip of the 
prepared merino, which is then dried, and exposed to the dull fed 
heat of a spirit lamp. If a trace of sugar be present, a black spot is 
produced. 

286. Bismuth Test.— Bottger has lately proposed a new test for 
sugar. This consists in adding first of all potash, then a small 
quantity of subnitrate of bismuth; lastly, the mixture is boiled. 
If sugar is present, the oxide is reduced to metallic bismuth, which 
is precipitated in the form of a black powder. It has been asserted 
that sulphuret of bismuth is formed, but this seems not to be the 
case. Briicke shows that this test is more delicate than Trommer's 
(or the modification of it by Fehling); and he finds that the black 
precipitate is produced to some extent in specimens of healthy urine. 
The bismuth test may be also applied thus. A solution of carbonate 
of soda (crystallised carbonate 1 part, water 3 parts) is prepared, 
and a certain quantity added to an equal amount of the urine. A 
little basic nitrate of bismuth is then added, and the mixture 
heated to the boiling point If sugar be present, a black precipitate 
is produced. 

286. Chromate of Potash Test.— If equal parts of neutral chrc^ 



232 ON ESTIMATING THE QUANTITY 

mate of potash and solution of potash be boiled with diabetic urine, 
a green colour, owing to the presence of oxide of chromium, is pro- 
duced (Horsley). Luton^s test is a modification of this. A solution 
of bichromate of potash is decomposed by excess of sulphuric acid, 
and, upon the urine being boiled with the mixture, a beautiful green 
colour is produced. This reaction is not affected by urea, albumen, 
or the urates. 

On Estimating the Quantity or Sugar. 

The quantity of sugar is easily determined, though not with abso- 
lute accuracy, by fermentation. The quantity of carbonic acid 
formed may be measured, weighed directly, or its weight may be 
determined by ascertaining the loss of weight the urine has sus- 
tained from fermentation. 

287. On Estimating the Quantity of Sugrar by Fermentation. 
— If the carbonic acid is to be measured, the mixture of yeast and 
urine must be placed in a graduated tube inverted over mercury. 
When the fermentation is complete, which is generally the case in 
from six to twelve hours, at a temperature of 100°, the volume of 
gas may be read off, and, after correction for temperature and 
pressure (Miller's ^^ Elements of Chemistry y"* Vol. I., pp. 48, 180), 
the amount of sugar calculated. One grain of sugar corresponds to 
nearly one cubic inch of carbonic acid. 

The carbonic acid may be weighed by causing it to pass through 
a solution of liquor potassae, specific gravity 1250, in an ordinary 
Liebig's potash tube. One grain of carbonic acid corresponds to 
about two grains of grape-sugar. The urine (about 500 grains) with 
the yeast may be placed in a small retort, to the end of which is 
adapted a chloride of calcium tube, or a tube containing pumice- 
stone moistened with sulphuric acid, for the purpose of drying the 
gas. To the extremity of the drying tube the potash apparatus is 
connected. This is weighed just before and immediately after the 
fermentation, which should be allowed to proceed at a temperature of 
from 80° to 100° for twelve hours. The increase of weight is due to 
dry carbonic acid. Or, lastly, about 200 grains of urine with a little 
yeast are placed in a flask, to the mouth of which a small drying 
tube is adapted, as shown in Plate XIII., fig. 68. The disengaged 
carbonic acid passes through the little tube ^containing chloride of 



OF SUGAE m THE URINE. 233 

calcium or fragments of pumicestone moistened with strong sul- 
phuric acid, and escapes, while the watery vapour, which would other- 
wise pass away with it, is retained. The apparatus is to be carefully 
weighed before and after the experiment, and the loss indicates 
carbonic acid. 

The results afforded by fermentation are not so accurate as those 
obtained by the volumetric process of analysis, which are described 
in §§ 47, 48. 

288. Determination of Sugrar by the Polarisinsr Sacchari- 
meter. — Biot, many years ago, proposed a plan for estimating the 
proportion of sugar in fluids, depending upon the influence which 
the solution of sugar exerted upon a ray of polarised light made to 
pass through a thick stratum. Under these circumstances, a suc- 
cession of colours is produced in the following order : yellow ^ green, 
blue^ violet, red. If, in order to produce this series of changes, the 
hand must be turned towards the right, the solution is said to divert 
the plane of polarisation to the right, or to exhibit right-handed 
polarisation ; but if to the left, left-handed polarisation. Cane-sugar 
and diabetic sugar have the first property ; the sugar of fruits the 
second. The amount of rotation varies according to the quantity of 
sugar present. Two or three different forms of apparatus have been 
made. Mitscherlich's and Soleil's are well known. A modification 
of Mitscherlich's, made for me by Mr. Becker, of the firm of 
Elliott, Brothers, Strand, is represented in Plate XIII., Fig. 67. 
The urine or saccharine fluid is placed in the long tube. At the end 
near the lamp is a prism of Iceland spar, the polariser; and at 
the other extremity another prism, the analyser. The latter crystal 
is connected with a movable bar, which can be rotated with the hand, 
and the arc through which it is carried can be accurately measured 
on the graduated circle with the aid of a vernier. The instrument 
is placed with the posterior aperture about two inches from a homo- 
genous light,* and the prisms adapted to zero, which is found by 
arranging the posterior prism so that, the tube being empty, when 
the arm stands at zero, the little spectrum is quite dark. It is then 
ready for use. The tube is filled with the solution carefully filtered; 

* The best light is a very good Argand or Leslie's burner, with a piece of white 
porcelain, like a reflector, but having a dull surface, behind ; or a piece of thin ground- 
glass, or semi-opaque white gla^iS, may be placed in front of the lamp. 



234 DETERMINATION OP SUGAR 

and if dark coloured, it is to be decolourised in the first instance by 
animal charcoal. Upon moving the arm towards the right, it will 
be found that, after it has passed through a certain number of degrees, 
the colour of the spectrum becomes blue, and gradually violet and 
red. Now, the exact degree at which the colour passes from the 
violet to the red is to be noted ; and the number will vary according 
to the quantity of sugar. The value of each degree is ascertained 
by examining in the first instance a few solutions having known 
quantities of sugar dissolved. Supposing that 50 grains of sugar, 
dissolved in a certain quantity of water, require a rotation of 20°, 
100 grains in the same quantity of fluid will require a rotation of 40° 
before the violet colour would appear. This method is very simple 
and accurate. 

M. Clerget ("Annales de Chimie^^ III., xxvi., 175) used SoleiPs 
instrument, which was also employed by Dr. Bence Jones for deter- 
mining the quantity of sugar in wines and in diabetic urine. 
{^'Med, Times and Gazette;' Vol. XXV., 1852, p. 102.) The appa- 
ratus consists of a polariser and an analyser, made of Iceland spar. 
The light, which should be bright, white, and homogeneous, is placed 
behind the polariser. Between the polariser and analyser is placed 
the tube containing the saccharine solution, as in the other appa- 
ratus. Before reaching the saccharine solution, the rays of light 
pass through a circular plate of quartz, "composed of two half 
circles possessing equal and opposite rotatory power." The colour of 
the two plates will be the same before placing in the sugar, but 
afterwards the colour varies much; and by moving the (Compensator, 
composed of two wedges of quartz, which can be slipped over each 
other, the colour will be equalised. The amount of movement 
required, or the thickness of the quartz, varies according to the 
amount of sugar present; and thus the proportion may be deter- 
mined. 

The cheapest, and at the same time the most simple and efficient, 
polarising saccharimeter, for medical purposes, is that of Dubosq of 
Paris. It should, however, be graduated on both sides of zero. It 
may be obtained of JMessrs. Elliott, of the Strand, and other 
Philosophical Instrument Makers. 

289. Dr. Gtexrod^B Plan of Estimating the Quantity of 
Sugar.-— Dr. Garrod has lately devised an instrument for estimating 



BT THE POLARISING SACCHARIMETER. 235 

the quantity of sugar in urine, founded on the principle that the 
alteration of colour caused by boiling a mixture of diabetic sugar 
and carbonate of potash varies in intensity according to the quantity 
of sugar present. A standard solution is prepared for comparison, 
by boiling with the carbonate of potash, a solution containing half a 
grain of sugar to the fluid ounce. This is placed in a clear glass 
tube of about half an inch in diameter. The solution of carbonate 
of potash is prepared by dissolving four ounces of the carbonate in 
six ounces of water, and the solution filtered. 

In the first place, Moore's test is applied ; and if the colour pro- 
duced after boiling for a few minutes be deeper than an amber red, 
it is necessary to dilute the urine before making the quantitative 
determination. The darker the colour produced, the more the urine 
is diluted. An equal bulk, twice or three times its bulk, of water is 
to be added, according to circumstances ; the exact proportion added 
must, of course, be carefully noted. 

Thirty minims, by measure, of the urine, diluted or not, as the 
case may be, are mixed with an equal quantity of the carbonate of 
potash solution, and poured into a small flask. The measure is to 
be washed out with about a drachm and a half of water, which is 
also to be mixed with the solution. Next, the whole is to be boiled 
over a spirit-lamp for five minutes. When cool, the mixture is 
transferred to a graduated tube of the same calibre as that which 
contains the standard solution, and diluted with water until its tint 
is exactly the same as that of the standard solution. By a simple 
calculation, the quantity of sugar is easily found. Suppose it has 
been necessary to make the urine by dilution, forty times its original 
bulk, in order to obtain the exact tint, it will contain forty half- 
grains of sugar per ounce, or twenty grains of sugar. From these 
data, the proportion passed in the twenty-four hours is easily calcu- 
lated. The apparatus was made by Messrs. Coxeter. 

290. Dr. Roberts' T/Lode of estixuatin^ the Quantity of Sufirar. 
— Dr. Roberts estimates the quantity of sugar in urine by ascer- 
taining the difference in density of the fluid before the destruction 
of the sugar by fermentation, and after this process is complete. Two 
portions of urine, of four ounces each, are placed in separate bottles 
of about 12 ounces capacity. To one is added a piece of German 
yeast, about the size of a walnut; the other is tightly corked. Both 



236 OBSERVATIONS UPON 

are placed in a warm place for twenty-two hours, when fermentation 
will be complete. The bottles are then removed to a cooler part of 
the room, and when two hours have elapsed, the density of the fluid 
in each bottle is ascertained by the ordinary urinometer. Every 
degree of density lost by the fermented specimen indicates one grain 
of sugar in each fluid ounce of urine. {^'Edinburgh Medical Jour- 
nai;' October, 1861.) 

Obsebyations upon the Nature op Diabetes. 

It is not possible to discuss this question, without entering upon 
the consideration of the physiological changes which occur in the 
healthy liver, and I shall therefore venture to bring under the 
leader's notice several points, which are not only of physiological 
interest, but which really have a most important bearing upon 
medicine. 

It is almost needless to say, that the sugar, found in the urine in 
diabetes, is not formed by the kidney, since it may be detected in 
many secretions, and that modern research has proved conclusively 
that the liver is intimately concerned in the production of a 
substance, which is very readily converted into sugar. 

291. Amyloid or Gluoogrenio Matter. — In many animals, and 
in many different tissues of the same animal, a substance is found 
which is closely allied to starchy matters, and which very readily 
undergoes conversion into sugar. This amyloid matter is constantly 
found in the liver, and it is formed by the liver cells. It is probable 
that, in the adult mammalian animal, in perfect health, this amyloid 
matter is formed in quantity in the liver alone; but in certain 
morbid states it is found in many different tissues, in the muscles, 
in the coats of the arteries, veins, and capillaries, and in various 
glandular organs. Even in health there seems to be a certain 
quantity of amyloid material produced in. certain parts of the 
nervous system, and in several of the faetal tissues it is to be 
detected in considerable quantity. (Rouget) 

The amyloid or glucogenic matter very readily undergoes con- 
version into sugar. If injected into the blood, it becomes converted 
into sugar, which is carried off in the urine. 

292. Bernard's Besearohes.— The demonstration, by Bernard, 



THE NATURE OF DIABETES. 237 

of the presence of a large quantity of sugar in the liver of all 
animals, his discovery of the glucogenic material or amyloid matter, 
which hecomes converted into sugar, and the proofs he has 
adduced that the formation of sugar in the liver is influenced 
hy changes in the nervous system (for instance, by irritating the 
floor of the fourth ventricle, a temporary diabetic condition is 
induced), are, without doubt, the most important discoveries which 
have been made in physiology during the present century. Bernard 
considers that the glucogenic material or amyloid matter undergoes 
conversion into sugar, and that this sugar is at last oxidised and 
probably resolved under ordinary circumstances into carbonic acid. 
Under certain altered conditions, however, the whole of the sugar 
that is formed is not decomposed, but much accumulates in the 
blood, and is at length separated from the circulating fluid by the 
action of the kidneys; or, there may be a much more abundant 
formation of sugar than usual without any corresponding increase 
in the destructive processes, so that a large proportion circulates 
in the blood and is continually being carried off" in the urine. 

293. Dr. Pavy's Observations.— Dr. Pavy asserts that the con- 
version of the amyloid matter into sugar does not proceed during life 
in the healthy state, but that it takes place constantly in the liver 
after death, while in disease the change occurs during life. It has 
been stated by Bernard and others, that the blood of the portal vein 
often contains no sugar, while that of the hepatic vein contains a 
considerable quantity, but Dr. Pavy asserts on the other hand, that 
only the merest trace of sugar is to be detected in the blood of the 
right side of the heart during life, if proper precautions are used in 
obtaining the blood. He states that it is necessary that the animal 
should be perfectly tranquil at the time of the operation, as there is 
always much sugar if any struggling occurs. Again, if the liver of 
an animal, immediately after death, be injected with a strong 
solution of potash or citric acid (100 grs. to each ounce of water), 
sugar is not found. Or if small pieces of the liver, taken from an 
animal the instant it is killed, be quickly frozen, according to 
Dr. Pavy, the post-mortem formation of sugar is prevented, and 
sugar is not to be detected in the liver thus treated. 

If woorari or strychnine be injected beneath the skin of an 
animal near the medulla oblongata, diabetes is induced, and Dr. 



238 OBSERVATIONS UPON 

Pavy has shown that section of the medulla oblongata, artificial 
respiration being kept up, also causes it. The division of the 
sympathetic in the thorax, or even the branches ramifying on the 
carotid and vertebral arteries produces the same result. This 
observer, therefore, has been led to conclude that in the normal 
state, the medulla oblongata, through the branches of the sym- 
pathetic, exerts an influence upon the changes going on in the liver, 
and prevents in some way the conversion of amyloid matter into sugar. 

294. Dr. Harley's Observations.— Dr. Harley, on the other 
hand, considers that the formation of sugar does proceed during 
life, and in several experiments he has shown that sugar exists in 
the liver, although the greatest expedition has been employed in 
removing portions the instant death has taken place. Dr. Sharpey 
also took part in these experiments, and concurs in the conclusion 
that the presence of sugar in the liver is a natural condition, and 
not the result of post-mortem change. In one experiment the portal 
blood, at the instant of death, contained no sugar, while there was 
distinjct evidence of its presence in the hepatic blood, as Bernard has 
stated. {^^Proceedings of the Royal Society'' Vol. X., 1860, p. 290.) 

Dr. Thudichum has raised many objections to Dr. Pavy's method 
of analysis, and has proved that when air, potash, and sugar, are 
mixed together, the sugar is decomposed. This observer concludes 
that Dr. Pavy failed to discover sugar in the liver when he injected 
potash into the portal vein while the liver was yet warm, because 
the sugar had been destroyed ; while if the liver was allowed to cool 
first, sugar would be detected, because the whole of what was present 
would not have been destroyed. {^^ British Medical Journal March 
17th, 1860.) 

I have myself many times been surprised at the very distinct 
reaction which is obtained by testing cat's liver the instant death 
has occurred; and until Dr. Pavy has succeeded in obtaining portions 
of the healthy liver of the cat and dog without a trace of sugar, I 
think his view, that the liver does not form sugar during life in the 
healthy state, cannot be accepted. The least that can be said is that 
more conclusive experiments are undoubtedly required, before we 
shall be justified in giving up Bernard's view. 

295. Bemarks by the Author. — It seems to me almost proved 



THE NATURE OF DIABETES. 239 

that the changes which continue to take place in the liver for a short 
time after death, are of the very same nature as those which occurred 
in the organ before death. I have noticed that warm water may be 
caused to traverse the capillaries of the liver for several hours after 
death, and still indications of sugar exist in that which is received 
from the hepatic vein. Much more sugar can in this way be 
obtained than existed in the liver at the time of death. The blood 
is soon washed out, so that this can have nothing to do with the 
conversion of the amyloid into sugar. During life, under normal 
circumstances, one would only expect to find mere traces in the 
blood, as the sugar would be carried off as fast as it was formed, and 
probably itself decomposed as fast as it was carried off". 

I cannot think that the life of the animal can make all the 
difference which is supposed in the action of the liver. Surely if 
a considerable quantity of sugar can be demonstrated to exist in 
the liver immediately after death we are not justified in considering 
this a mere post-mortem change. A piece of cat's liver, the instant 
death has taken place, exhibits the presence of sugar in precisely the 
same manner as a piece of the same liver removed during life. It 
is doubtful if the death of the great central organs of the nervous 
system produces that immediate change in many of the nutritive 
and secreting operations of the body, which the supposed necessity 
for this very quick removal of the liver seems to argue. 

Nor is it an answer to this objection to say that as certain of the 
nerve cells cease to manifest any activity the instant death takes 
place, it is possible that the liver cells may as instantly cease to 
perform their functions. We know that there are some cells which 
may exhibit their actions for a long time after death, and which will 
retain their vitality, so that they can be removed from one organism 
to another. The liver cells are more likely to agree in character 
with the cells of glands and secreting surfaces generally than they 
are with those of the very highest tissue in nature, and therefore it 
is impossible to resist the inference, except in the case of positive 
demonstration to the contrary, that the same substances are formed 
by these cells a few seconds after death, as were produced by them 
a few seconds before death. 

There is no reason for supposing that the liver cell, unlike many 
other cells connected with different secreting organs, dies the instant 
the death of the animal takes place. Just as we have ciliary action 



240 THE NATURE OF DIABETES. 

and other changes continuing in individual cells for some time after 
the death of the animal in whose organism they were found, so also 
we may reasonably conclude that changes which have been going on 
during the life of the animal really continue to occur in the cells 
for a certain time after its death. 

Moreover, it is most probable that the changes taking place in 
the amyloid matter of the liver cell are not vital changes at all, but 
due rather to chemical and physical actions only. The outer part 
of the formed material of a liver cell in the living body is no more 
alive than the outer part of the formed material of a soft epithelial 
or of a cuticular cell That physical and chemical changes may go 
on at a different rate, according as the blood is flowing quickly, 
slowly, or not at all, is reasonable, but actual demonstration is 
required before a view which supposes the changes occurring a few 
seconds before death to be essentially different from those taking 
place a few seconds after death, can be accepted. The opinion that 
the conversion of amyloid into sugar is essentially a post-mortem 
or abnormal change, may be entertained, but no one has yet suc- 
ceeded in demonstrating that this opinion is correct. 

296. On the Pozmation of Amyloid, Fat, &o., in the Liver 
OelL — The different substances taken as food are not simply reduced 
to a soluble state in the stomach and intestines, and then absorbed ; 
nor are they alone rendered soluble, and altered in physical and 
chemical characters by the secretions of the different glandular 
organs which are mixed with them, but they are taken up by the 
living matter of the cells, and completely new substances at length 
result ; so that the fat, amyloid, and sugar, which may be obtained 
from the liver, are not the same substances as were absorbed from the 
intestines, nor are they the substances absorbed somewhat modified, 
but it is probable that they are new bodies altogether, possessing 
certain definite characters. The general opinion now held by physio- 
logists is, undoubtedly, that the substances absorbed at the intestinal 
surface simply undergo change. But how is the change effected? 
Most physiologists seem to consider that change is effected while the 
materials in solution are in the blood, or during their passage 
through narrow channels on their way towards the chyle or blood ; 
and attempts have been made to show that minute channels exist 
through the epithelium of the intestine, which lead by the narrow 



OF THE ACTION OF THE CELL. 241 

extremity of the cell into the connective tissue corpuscles of 
the villus. What are the agents that effect the change in the 
fluid passing through the cells 1 This converting power is generally 
ascribed to the nuclei ; but there is no evidence that nuclei have 
any power of exerting an influence or change upon matter which is 
at a distance from them. Moreover, it has been shown that soluble 
matters pass into the very substance of the nucleus, and that, under 
certain circumstances, the absorbed matter goes to increase the 
matter of which the nucleus is composed ; while the outer particles 
of the nucleus (germinal matter) are resolved into new constituents, 
the new matter taking the place of this which becomes changed. The 
nucleus may remain of the same size, although a vast amount of 
nutrient matter has been taken up, and a corresponding proportion 
of new substances has been formed. 

This is the meaning of the vast quantity of nucleus (germinal) 
matter existing in connection with every absorbing surface and in 
every gland. The pabulum does not simply pass between these 
nuclei or cells, but it passes into their substance, and becomes 
living germinal matter. Its whole relations are changed, and it 
becomes endowed with powers like that of the living matter which 
existed before it. The older living particles, in dying, become 
resolved into new but inanimate substances. The elements form 
new combinations. These compounds result, not from any changing 
powers of the nucleus acting at a distance, but depend upon the 
relation which the elements were caused to assume just before the 
death of the living matter, and the external conditions which existed 
at the time the death of the particles occurred. 

The fat, amyloid, and sugar, after disappearing from the intes- 
tines, become completely changed, and entirely lose all their 
characteristics. They served but as pabulum to certain cells, which 
lived upon them and grew. The living particles of these ceUs at 
length die, and among the substances formed may be other kinds of 
fatty, amyloid, and saccharine matters; but these are new bodies, 
not the altered starch, fat, and sugar that were absorbed. 

When sugar is absorbed from the intestine the quantity of amy- 
loid in the liver is increased; and this has been used by Dr. Pavy as 
another argument against the glycogenic theory. He says that: 
" Instead of the liver allowing sugar to pass through it, and also 
producing sugar itself, it transforms that which reaches it into amy- 

M 



242 OF THE FORMATION OF BILE, 

loid substance." This fact of the increase of the amyloid is no 
argument against the conversion of this into sugar under normal 
circumstances, unless it can be shown that the amyloid afterwards 
gradually disappears without undergoing conversion into sugar. 

It is quite true that the supporters of the glycogenic theory have 
&iled to show in what form the sugar is ultimately eliminated or 
applied to farther purposes in the economy ; but there seems to be a 
greater diflficulty in accounting for the subsequent changes in the 
amyloid matter if we suppose that, normally, it does not undergo 
conversion into sugar. The conclusion that the amyloid undergoes 
conversion into fat requires to be supported by stronger evidence 
than has yet been adduced, before it can be accepted. 

It must be borne in mind that the cells, at the circumference of 
the lobules of the liver, are those which become first gorged with fat 
in fatty liver, and that these are the cells which are principally con- 
cerned in the formation of bile. In cases of amyloid liver, the cells 
near the centre of the lobules are those which become so enormously 
enlarged in consequence of the accumulation of this amyloid matter. 
Are we to infer that, normally, amyloid is formed principally in the 
central part of the lobule, and bile and fat are produced at the cir- 
cumference ; or that the amyloid formed in the central part gradually 
becomes resolved into bile and fat as the cells gradually pass from 
the centre towards the circumference of the lobule ? This cannot be 
so, because, to render it possible, the cells must move in a direction, 
from the centre to the circumference of the lobule, much more 
rapidly than is actually the case. 

Looking at the question from an anatomical point of view, many 
facts tend rather to the conclusion that the marginal cells are those 
mainly concerned in functional activity, and that those near the 
centre are being developed, and will gradually take the place of the 
former as they are removed. In the normal state the central cells 
are certainly not actively concerned in secretion {see my Papers on 
the Anatomy of the Liver). I incline to the view that, in health, 
the amyloid matter is formed in the same cells with the fat globules, 
and that the outer part of these cells is being resolved into two 
classes of substances — ^biliary matters which do not permeate the 
ducts, and certain substances which readily permeate animal mem- 
brane, and are reabsorbed with the fluid which is removed from the 
bile soon after it is formed, while it passes along the ducts. Further 



AMYLOID, PAT, AND SUGAR. 243 

provision for the removal of such soluble substances exists in the 
gall bladder where further inspissation takes place. Amyloid readily 
becomes converted into sugar, but no one has succeeded in causing 
it to split up into sugar and fatty or biliary matters ; but it is quite 
possible that the matter of which the outer part of the liver cell 
consists, may split into the above two classes of substances — ^the one 
class permeating animal membrane, the other possessing but very 
slight permeating properties. 

297. Dr. McDonnell's Observations.— Dr. McDonnell {^^Pro- 
ceedings of the Royal Society, ^^ Vol, xii. 1863, p. 476) concurs in the 
views expressed by Dr. Pavy as to the amyloid matter not being 
transformed into sugar, under normal circumstances, during life, and 
endeavours to ascertain what becomes of this amyloid substance 
formed, not only in the healthy liver, but in the foetus in many other 
tissues, such as the skin, horny tissues, muscles, &c. During active 
digestion. Dr. McDonnell has found, that the blood which leaves the 
liver, contains a protein compound resembling caseine, in larger 
quantity than ordinary arterial or venous blood. This he thinks 
results from the union of the nitrogen of the fibrin and albumen, 
decomposed in the liver, with the amyloid material. He conceives 
that the hydro-carbonous substances resulting from the disintegra- 
tion of fibrin and albumen in the liver are thrown out as bile, while 
the nitrogen of these compounds reunites with amyloid to form this 
new substance like casein, which passes away in the hepatic blood. 

298. Of the Formed Material of the Liver-Cell and of the 
Changes occarrinff in it. — The amyloid matter is found in the cells 
when no saccharine or starchy materials are taken in the food, and 
this is a strong argument against the view which concludes that it 
results from some assumed and unexplained metabolic action of the 
nucleus or cell wall, upon starchy or saccharine matters brought to 
the liver in the portal blood. In fact, we can obtain, among other 
substances, from the liver -cell, amyloid matter, albuminous matter, 
and fatty matter. Each of these constituents may vary greatly in 
quantity in the cells, but it has not been shown that the fat or 
albuminous matter results from changes occurring in the amyloid 
substance, or that the albuminous matter is resolved into fiitty and 
amyloid. The germinal matter of the liver-cell gives rise to certain 

M 3 



244 OF THE FORMED MATERIAL 

substances, of which the outer part of the cell or ^formed material ' 
is composed. (There is no limitary membrane, or *cell wall,* to the 
liver cell.) Among these may be recognised, albuminous matters^ 
fatty matters, amyloid matters, colouring matters, but these are 
themselves undergoing change. It appears that the principal 
substances resulting from the disintegration of this formed material, 
under normal conditions, are biliary matters, which are excreted, 
and other substances which again pass into the blood. Among these 
latter are an albuminous material closely allied to casein, and a 
substance which probably takes part in the production of heat. 
This, according to the theory of Bernard, is sugar, resulting from 
changes occurring in amyloid matter ; while Dr. Pavy considers that 
the substance resulting from the amyloid is more nearly related to 
the fatty class. 

There can be no doubt that the relative proportion of the 
different constituents, which can be recognised in the formed 
material of the liver-cell, differs greatly in different animals, and in 
the same animal under different circumstances and at different times. 
The proportion of these constituents is greatly influenced by the 
nature of the food. It is clear that the varying proportion of oxygen 
in the blood, transmitted to the liver, will influence the proportion 
of the several constituents, resulting from the disintegration of the 
formed material, in a remarkable degree. The diminished supply of 
oxygen may cause the accumulation of a large quantity of fat in the 
liver-cells, while a large supply would have resulted in the secretion 
of an increased quantity of bile. This subject requires most ex- 
tended research, but it seems to me that observations should be made 
from this point of view : — ^that the substances formed in the liver, 
some of which pass to the intestines in the form of bile, while others 
pursue an opposite direction and are carried in the blood to the 
lungs, result from the disintegration of the material, of which the 
outer part of the so-called liver-cell is composed, and are not due to 
any action exerted by the nucleus upon matters passing by or 
into, or simply coming into contact with, the cell, nor to any peculiar 
powers exerted by the supposed cell wall. 

As to the ultimate changes of the sugar, supposing it to be pro- 
duced normally, or of the amyloid, or the fat supposed to result from 
it, nothing positive is known. Bernard, without attempting to 
explain the successive changes, concludes that the sugar is at length 



OF THE LIVER CELL. 245 

destroyed and excreted in the form of carbonic acid ; and even Dr. 
Pavy, in his earlier experiments, showed that blood which exhibited 
strong indications of a quantity of sugar, was found to contain only 
traces after it had been caused to traverse the capillaries of the lungs. 
It is true that a solution of pure sugar is not decomposed by the 
direct action of oxygen, but this is no argument against the view 
that sugar in the venous blood is ultimately resolved into carbonic 
acid; for it is quite obvious that oxidation, as carried on in the 
body, occurs under conditions very different from those we are able 
to bring about in our laboratories. In fact Dr. Pavy himself showed 
that the destruction of sugar by respiration occurs only in blood 
which contains fibrin. 

No one has any doubt that, in the majority of diseases known 
to us, this very process of oxidation is at fault. There may be 
quite oxygen enough in the fluids' of the body, but the state in 
which it exists may be different, the conditions favouring its com- 
bination may be absent, or the substances may not be presented to 
its action in the normal manner, and so they are not decomposed. 
There are probably many compounds between the sugar which passes 
from the liver and the carbonic acid which is evolved from the lungs. 
This sugar may, under normal conditions, be taken up by the masses 
of germinal matter (cells, nuclei) existing in such great number in 
relation with the capillaries of the lungs, and the particles of which 
these cells consist, may become resolved into carbonic acid, among 
other substances, or the sugar may be taken up by the blood cor- 
puscles, and the matter of which these bodies are composed resolved 
into carbonic acid and other matters. I merely offer these specu- 
lations for the purpose of showing that there yet remains much to be 
decided before we shall know precisely how fat, sugar, amyloid, and 
many other substances, become oxidised in the living organism. 

With regard to this most difficult and highly interesting question, 
it seems to me that, in the present state of knowledge, the greatest 
caution ought to be exercised in forming a general conclusion. But 
I cannot help stating that, as far as I am able to judge, the evidence 
is at present strongly in favour of Bernard's view, that, in health, 
sugar is produced in the liver, and destroyed whilst it is in the 
blood. In the normal state the destruction of the sugar occurs at the 
same rate as its formation ; while in certain lesions of the nervous 
system, and under other circumstances, more sugar is formed than 



246 CUMICAL IMFOBTANCE 

can be destroyed — or the quantity formed remaining the same, the 
normal conditions nnder which its decomposition takes place being 
absent or modified, it accomnlates in the blood, and is excreted by 
the kidneys and other secreting organs, thns producing diabetes. 
Whether the excretion of a large quantity of sugar in the urine 
depends upon increased activity of the sugar-forming process, or 
results from the cessation of the destructiye changes which occur 
normally, has not been determined. There can be no doubt that 
certain parts of the nervous system are seriously implicated in aU 
cases, but whether the nerves exert a direct influence upon the 
sugar-forming or sugar-destroying processes, or only affect these 
operations indirectly through the control they exert upon the 
calibre of the arteries, and therefore upon the quantity of arterial 
blood distributed to the capillaries, is not known; but there are, 
I think, many facts which favour the latter view, while it has never 
been shown that nerves exert any direct influence upon the growth 
or action of any cells. They influence the processes of growth, for- 
mation, and secretion, by regulating the supply of nutrient material; 
and the process of disintegration is affected by the quantity of the 
soluble constituents of blood, rich in oxygen, that is permitted to 
bathe by the cells. 

299. Of the Cflinical Importance of Sugrar in the XTrine. — 
The existence of sugar as a normal constituent of urine has been 
already referred to (§ 267), but it is not uncommon to meet with 
specimens of urine from persons apparently in the enjoyment of good 
health, which exhibit unmistakeable evidence of the presence of sugar, 
there being sufficient to estimate quantitatively, without resorting to 
the processes referred to in §§ 280, 281, which are necessary to obtain 
evidence of the traces said to exist in specimens of healthy urine. I 
have often found from one to two grains of sugar in 1000 of urine, 
in cases where all traces of the presence of this substance have 
disappeared in a few days, without any of the usual restrictions as to 
diet; and I have noticed the presence of small quantities of sugar in 
the urine more frequent during the summer than during the winter 
months. I know other practitioners have made the same obser- 
vation, and sometimes there exists much difference of opinion as to 
whether a patient has, or has not, diabetes. A short time since, I 
found very positive indications in the urine of a gentleman, who I 



OF SUGAR IN THE URINE. 247 

found, upon inquiry, had been in tlie habit of eating a large quantity 
of sugar with fruit tarts. Brown bread, restriction of sugar within 
moderate limits, and salines, soon caused the sugar to disappear from 
the urine. But in cases of fatty liver, and in that common condition 
in persons who live too well, where the liver is somewhat wasted as 
well as fatty, it is very common to find sugar in the urine. The 
diabetic condition, in these cases, may persist for weeks or months 
and then pass off entirely. 

The highly important and interesting observations lately made 
by M. Hohl, in a case of diabetes where inosite (§ 321) was passed in 
large quantities, and seemed to take the place of the urea and sugar, 
must not be passed over. 

The quantity of sugar is always much influenced by the quantity 
and nature of the food. It increases shortly after a meal, and it is 
undoubtedly augmented when much starch is taken. A meat diet, 
with bran or gluten bread, always causes a diminution of the sugar. 
Total abstinence from food, and rest, diminish the proportion; and 
it is increased by exercise, and by a large quantity of food. As much 
as two pounds of sugar may be excreted daily; but about one pound 
is the more usual quantity. I have now (1858) under my care, a 
girl, aged 19, who excretes daily about one pound and a half of sugar. 

The dry harsh skin, the intense hunger and thirst, the emaciation, 
the tendency to the formation of tubercle in the lungs and other 
organs, are familiar to all who are acquainted with the clinical 
history of this disease. Dr. Garrod observes, that oedema of the legs 
is always present in diabetes. Although in some cases it is very 
slight, he states that it is always to be detected. I have failed to 
observe it in one instance. 

Sugar has been found in the urine in cases of cholera, by Dr. 
Hassall and also by Heintz, but the former observer suggests that, 
as Heller has shown in this disease that the uroxanthin is in 
abnormal quantity, it is very probable that the sugar may be derived 
from this substance from decomposition. The same change may 
account for the presence of traces of sugar in many cases. (See § 267.) 
A diabetic state may be temporarily induced in animals, by certain 
lesions of the nervous system, but the condition soon passes off. 
Diabetes is a disease which does not occur in animals. Dr. Prout 
regarded diabetes as a form of dyspepsia, characterised by difficulty 
in assimilating the saccharine alimentary principle. 



248 OF CATARACT IN DIABETES. 

There can be little doubt that the liver is the gland which is 
essentially involved, although hitherto the nature of the lesion has 
not been discovered; indeed, no alteration, constant in all cases of the 
disease, has been made out by anatomical investigation. Diabetes is 
one of those diseases which often runs in families, and it is hereditary. 
The diabetic state is often temporary. It has been caused by 
injuries to the head. Dr. Gull and Dr. Barlow refer to cases in 
which it followed an attack of hemiplegia. 

I have, myseli^ found sugar in the urine in pneumonia and 
phthisis, and have frequently met with it in cases of gradual con- 
traction of the liver, accompanied with a corresponding condition of 
the kidneys, with albuminous urine. In one case the sugar and 
albumen seemed to alternate. Sugar would be present for a few 
days, while no albumen could be detected, and then albumen would 
appear and the sugar would cease for a time. Diabetes is generally 
accompanied with emaciation, but I have seen cases in which the 
patient was not only well nourished but corpulent. Not long since, 
I was consulted by a very robust and healthy-looking man, a farmer, 
weighing 13 stone, 6 lbs., who appeared to be suffering from dyspepsia. 
It was, however, found, upon examination, that the urine was of 
specific gravity 1028, contained a considerable quantity of sugar 
(38 grains in 1,000), and was loaded with albumen. There were no 
casts of the uriniferous tubes or other indications of renal disease. 
This case gradually became worse, although the proportion of sugar 
in the urine became reduced when he was put upon a properly 
regulated diet. 

In cases of carbuncle, sugar sometimes appears in the urine, and 
towards the close of chronic exhausting diseases it has been detected. 

800. Cataract in Diabetes. — It is well known that cataract is 
very frequently observed in diabetes, and sometimes at an early stage 
of the disease. Mr. Bowman has often diagnosed diabetes from the 
presence of cataract. Dr. G. Weir Mitchell and Dr. Richardson have 
shown that cataract could be caused in the frog, by injecting syrup 
under the skin, and they arrived at the conclusion that the opacity 
of the lens depended only upon the increase in the density of the 
fluids which bathed and permeated it. But it is probable that 
cataract, as it occurs in diabetic patients, is not due solely to this 
cause, seeing that it is not present in some of the worst cases of 



ORiam OF UREA IN DIABETES. 249 

diabetes, and exists in some slight cases in which the urine never 
reaches a high specific gravity. The cataract, too, will continue, 
although the diabetic state becomes much improved or passes off 
entirely. 

In diabetes, wounds do not heal satisfactorily, and the surgeon 
should, if possible, avoid performing even a slight operation in cases 
of this disease. 

801. Orierin of the largre Quantity of TTrea in Diabetes. — 

There can be no doubt whatever that, in many cases of diabetes, the 
sugar excreted in the urine is not derived solely from the starchy 
matters taken in the food; for although the patient may be restricted 
to a diet consisting entirely of proteine and fatty substances, sugar is 
found in the urine. 

The recent observations of the Rev. S. Haughton have confirmed 
this conclusion. He shows, in some cases which he investigated 
with the greatest care, that the sugar excreted had a double origin, 
having been in part derived from the starch in the food, and partly 
from the decomposition of proteine substance. He considers that 
the proteine compounds resolve themselves into glucose and urea 
without giving out work, the total work done in the body in diabetes 
being at a minimum. The large excretion of urea depends not upon 
the work done in the body, as in health, but results merely from 
decomposition. In this way the large excretion of urea is explained; 
and this cannot be accounted for upon the usual theory, that the 
urea is derived solely from the disintegration of tissue. (" On the 
Phenomena of Diabetes MeUitiis" Dublin, 1861.) 

802. Sugrar in the ITrine in Disease of the Respiratory 
Orgrans.— Sugar has been detected in cases of disease of the respiK^- 
tory organs, as pneumonia and bronchitis. In extreme cases of 
phthisis, sugar is occasionally detected in the urine, and towards the 
close of many exhausting diseases, a meal of starch is followed by the 
excretion of saccharine urine. I have shown the presence of a 
considerable quantity of sugar in the sputum in a case of acute 
pneumonia, just before the patient's death. It has been asserted by 
some observers, that sugar can always be detected in the urine after 
anaesthesia produced by chloroform, and in cases of bronchitis and 
emphysema. I have carefully tested for sugar in the urine of several 
patients who had taken chloroform, but did not succeed in detecting 

M 5 



250 SUGAB IN THE UBINE IN 

it in a single instance. The presence of sugar is accounted for under 
these drcumstances, on the supposition that in disease of the pul- 
monary organs the sugar is not further oxidised, and carried off as 
carbonic acid. But Bernard has shown that this theory has no 
foundation, and has proved that the condition of temporary dia- 
betes produced by irritation of the floor of the fourth ventricle, 
dose to the origin of the pneumogastric nerves, is not due to the 
impaired action of the respiratory organs, as Reynoso and others 
have supposed. 

Bernard has brought forward various facts which militate against 
the above view; as, for instance, no sugar appears in the urine after 
complete section of the pneumogastric nerves, and in many other 
conditions where the respiratory function is impaired. Nevertheless, 
Reynoso {"Comptea Eendus," t. XXXIII., XXXIV.) states that 
sugar is present in the urine of persons who have been placed under 
the influence of chloroform, bichloride and iodide of mercury, salts 
of antimony, opium and narcotics generally, quinine, and carbonate 
of iron. He also states that, in pleurisy, asthma, and chronic bron- 
chitis, hysteria, and epilepsy, he discovered sugar in the urine. The 
test employed, it is very important to observe, was Barreswil's solu- 
tion ; but before applying it, the extractive matters were removed. 
About 1,600 grains of the urine to be tested were treated with a 
solution of subacetate of lead. The precipitate was collected on a 
filter, and the excess of lead salt in the filtrate was decomposed by 
chloride of sodium ; and the solution was again filtered. The clear 
fluid, after being concentrated, was treated with the copper solution. 
To another portion the yeast test was applied. 

Michda, who, it should be observed, employed Moore's test, failed 
to confirm the above conclusions. D6chambre {"Gazette Medicale,'' 
1852) found sugar in specimens of urine obtained from several old 
people. The test employed was the same as Reynoso used, except 
that the excess of acetate of lead was decomposed with carbonate of 
soda instead of chloride of sodium. Dr. Bence Jones obtained 
"slight, but distinct" evidence of the presence of sugar ih the urine 
of a patient who had been twenty-four hours under the influence of 
chloroform. The urine was examined according to Reynoso's direc- 
tions. M. Blot also confirms Reynoso's observations to a great 
extent. He found sugar in the urine of pregnant women, and in 
those who are suckling children as soon as the milk was secreted. 



DISEASES OF THE BESPIBATORT ORGANS. 251 

It is possible that affections of the respiratory organs may be instru- 
mental in producing the diabetic condition ; but this may be due to 
the excitation of the peripheral extremities of the pneumogastrics, 
depending upon the altered state of the pulmonary membrane, being 
propagated aJong the trunks of nerves to that particular part of the 
medulla oblongata the artificial irritation of which in animals is 
known to induce diabetes. There are many facts which support the 
doctrine that the processes concerned in the production of the sugar 
are capable of being excited in a reflex manner, and they may there- 
fore be included in the excito-secretory actions. 

These observations of Reynoso and others seemed to be so 
important, that it was very desirable to repeat them. I therefore 
tried numerous experiments, but was unable to confirm the results. 
I often found the fluid change to a brown colour when heated with 
the copper solution; but, as I have shown, this is not a proof of the 
presence of sugar. I never conclude that sugar is present in a 
specimen of urine, unless a decided precipitate of the suboxide of 
copper is produced. Though this precipitate be very slight, it is 
characteristic. If it only amount to an opalescence, as I have before 
stated, it is sufficient ; but a change of colour even to a dark brown, 
the solution still remaining clear, does not, I believe, indicate the 
presence of sugar. 

These unsatisfactory results led me to institute the experiments 
upon the action of Barreswil's and Fehling's solutions, and different 
forms of the copper-test, which have been already described. 

808. The Experiments of Beynoso and Dechambre repeated, 
with Negrative Results.— The urine was tested as in Reynoso's 
experiments, except that carbonate of soda was used to precipitate 
the excess of subacetate of lead, instead of chloride of sodium. The 
specimens of urine passed by six patients under the influence of 
chloroform, for periods of time varying from ten minutes to half an 
hour, that of an old lady aged 87, of an old man aged 96, and of two 
children suffering from epilepsy, were carefully examined. In most, 
the solution became brown upon being boiled ; but no opalescence 
or precipitate was produced. The urine of a healthy man, aged 24, 
was also subjected to examination, and became brown upon being 
boiled with the copper test. The results of numerous other experi- 
ments upon specimens of urine known to contain no sugar led me to 



252 ANALYSES OF DIABETIC UEINE. 

the conclusion that, in all the above cases, the urine was perfectly 
free from this substance. Kletzinsky has repeated Reynoso's experi- 
ments, and has failed to confirm his conclusions. Dr. Moore of 
Dublin (Heller's " Pathological Chemistry of the Urine,^' translated 
by W. D. Moore, A.B., M.RT.C.D.) has examined the urine of twelve 
men and women whose ages varied from sixty to eighty-three, but 
was unable to detect sugar. We may, therefore, conclude that there 
is at present not sufficient evidence to prove that sugar is hahittLaUy 
excreted in the urine of old people, or by patients suffering from 
chest-disease, or by those under the influence of chloroform, etc. It 
is probable that it may be occasionally met with in some of the 
above cases. 

304. Analyses of Diabetic TTrine.— It is difficult to estimate 
the urea in diabetic urine by the old process ; but the proportion 
may be ascertained by the volumetric method, which has been 
described (§ 48). The following analyses show the composition of 
the urine in some cases of diabetes. 

Analysis 50. — Urine from a girl aged 19. Specific gravity, 
1037 ; acid, clear, pale. 

Analysis 51. — From the same. Specific gravity, 1036 ; acid. 

Analysis 52. — From a man aged 30, about one month before 
death. Specific gravity, 1023. 

Analysis 53. — From a woman aged 28, a week before death. 
Acid ; specific gravity, 1027. 

Analysis 54. — From a patient who was passing sixty ounces of 
urine daily. Reaction acid; specific gravity, 1021. 

Analyses. 

50 51 52 



916-50 894-90 946-8 

83-50 100 105-10 100 53-2 100 

1 82-29 78-2 

10-66 12-96 3-82 3-63 5-44 10*22 



Water . 
Solid matters 

Urea. 

Eztractives 

Uric acid 

Alkaline salts 

Earthy salts 

Sugar . not esthnated. 18-99 18*08 20*24 38-04 



TREATMENT OP DIABETES. 253 



Water 


934-2 




94600 


"~^ 


Solid matter 


. 65*8 


100 


54-00 


100 


Urea 

Extractive matters , 

Uric acid . 


16-94 
1-64 


25-74 
2-49 


I 21-54 


3918 


Alkaline salts 
Earthy salts 
Sugar 


1 5-82 
. 41-40 


8-84 
62-91 


3-76 
28-50 


6-96 
52-7 



Analyses 65, 56, 67 represent the composition of the urine in a 
case of diabetes now under my care in the hospital. The patient 
was a healthy-looking girl, only eighteen years of age. She had 
been suffering from the disease for about three months. Various 
plans of treatment were tried, without any marked results. She 
remained under treatment for six weeks, and then left the hospital. 
She drank from four to six pints of fluid daily ; and, when living on 
a moderate meat diet, with a small quantity of bread, passed rather 
under a gallon of urine. The urine was analysed from day to day ; 
and I select three specimens for illustration. When the last was 
obtained, her diet was restricted to bran-biscuits and milk. The 
results are expressed in grains, and represent the quantities passed 
in twenty-four hours. [See Table, next page.] 



The Treatment of Diabetes. 

805. Of the Treatment of Diabetes. — In the treatment of a 
case of diabetes, careful regulation of the diet is of the first impor- 
tance. That starchy and saccharine substances taken in the food, 
cause an increased quantity of sugar in the urine, is proved beyond 
question, while, on the other hand, every practitioner is familiar 
with the improvement that invariably takes place in the condition 
of the diabetic patient, even a very short time after these and allied 
substances have been diminished in proportion, or withheld. 

There are many cases of slight diabetes which recover directly 
starchy and saccharine matters are avoided, or even reduced in 
quantity. In such cases it would seem that the sugar in the urine 
is derived from those substances, while in very severe caSes the ex- 
cretion of sugar continues, although the patient lives upon a diet 



254 















F-H eo eo eo 




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TREATMENT OP DIABETES. 255 

consisting of albuminous matters and bran only. Patients suffering 
from the first form of the malady live for many years, and if proper 
precautions are taken, the disease may long be kept in abeyance, if 
it cannot be completely cured. In many cases the diabetic condition 
lasts for a certain time, passes off, and afber an interval reappears. 
The disease may continue for many years, or it may carry off the 
patient in a few months. It is rare for a confirmed case to recover 
completely. 

Except in very severe cases, it is neither expedient nor necessary 
to insist too strongly upon a very strict diet immediately the patient 
comes under treatment, for many rebel if this is attempted at once, 
who might be induced to submit to a folly restricted diet, if the 
system was introduced gradually. The quantity of wheaten bread 
may, at first, be reduced, and the proportion of meat may be 
increased, and brown may be substituted for white bread. Then 
some of the bran food may be tried, and gradually made to take the 
place of bread, and by employing a little ingenuity in using bran, 
eggs, cream, and glycerine, a perfectly restricted diet may be enforced 
without distress to the patient. The diabetic may be allowed to 
take his tea and coffee with cream instead of milk ; we may allow 
jellies of various kinds, but of course they should not be sweetened 
with sugar. But we are no longer compelled to deny even sweet 
flavours to the diabetic, for he may use glycerine ; the preparation 
now made so largely by Messrs. Price (Price's glycerine) is so pure, 
and its taste is so perfectly sweet, that it can hardly be distinguished 
from sugar. 

Glycerine may be used for sweetening tea, coffee, and cocoa, it 
may be introduced in custards, and with eggs and gluten bread well 
softened, a very palatable kind of pudding may be prepared ; 
glycerine, eggs, and bran may also be made into a light sort of cake 
or pudding, which may serve to vary the monotony of a strict diet. 

The diabetic patient may be allowed a moderate quantity of milk, 
but it should be borne in mind that milk contains a form of sugar, 
and, therefore, is not to form a staple article of food in this disease. 
Various kinds of meat and fish may be taken. Fat and butter do 
no harm. Eggs may be taken if they agree with the patient, but 
sometimes they upset the stomach. Soups of various kinds — ^but not 
containing flour— cheese, cream cheese, cream, ham and bacon, 
may be eaten by diabetic patients. 



256 TREATMENT OF DIABETES. 

306. Substitutes for Bread.— Some of the best subtitutes for 
wheaten bread are Bourchardafs gluten bread, or M, Durands 
Touhme gluten bread, CaUard!s English gluten, but the bran 
biscuits, prepared as Dr. Camplin directs, are far superior to either 
of these. The first contains about 25, and the Toulouse bread 26 per 
cent of starch, while the last contains only traces of this material 
when properly prepared. 

807. Formula for makinfir Bran Cakes.— Dr. Camplin, who has 
himself suffered from diabetes, has proposed a most yaluable kind of 
food made from bran. The bran is ground fine in a mill, sifted, and 
can then be made into a kind of cake. The directions Dr. Camplin 
gives are as follows — " Take a sufficient quantity (say a quart) of 
wheat bran, boil it in two successive waters for a quarter of an hour, 
each time straining it through a sieve, then wash it well with cold 
water (on the sieve) until the water runs off perfectly clear ; squeeze 
the bran in a cloth as dry as you can, then spread it thinly on a 
dish, and place it in a slow oven ; if put in at night let it remain 
until the morning, when, if perfectly dry and crisp, it will be fit for 
grinding. The bran thus prepared must be ground in a fine mill, 
and sifted through a wire sieve of such fineness as to require the use 
of a brush to pass it through ; that which remains in the sieve must 
be ground again until it becomes quite soft and fine.* Take of this 
bran powder 3 ounces (some patients use 4 ounces, the other ingre- 
dients as follows), three new-laid eggs, 1^ ounce (or 2 ounces, if de- 
sired,) of butter, about half-a-pint of milk; mix the eggs with a little 
of the milk, and warm the butter with the other portion ; then stir 
the whole well together, adding a little nutmeg and ginger, or any 
other agreeable spice. Bake in small tins (p^ttipans), which must 
be well buttered, in a rather quick oven for about half-an-hour. 
The cakes, when baked, should be a little thicker than a captain's 
biscuit; they may be eaten with meat or cheese, for breakfast, 
dinner, and supper; at tea they require rather a free allowance of 
butter, or may be eaten with curd or any of the soft cheeses. It is 
important that the above directions as to washing and drying should 
be exactly followed, in order that it may be freed from starch, and 
rendered more friable." ("On Diabetes" page 86.) The mill may be 
obtained from Mr. Gollop, 149, Cheapside. 

* This is particularly necessary in cases of irritable bowels. 



TREATMENT OF DIABETES. 257 

The bran powder and biscuits cost Is. 6d. per pound. The 
gluten biscuits cost 28. 6d. a pound. 

308. Almond Cake.— Dr. Pavy (" On Diabetes," p. 154) has 
recently added another substitute for wheaten bread — ^Almond cake 
and bread. A very palatable kind of biscuit has been prepared with 
egg and blanched aJmond powder, according to Dr. Pav/s suggestions, 
by Mr. Hill, of Bishopsgate Street. Upon this diet, the quantity of 
sugar in the urine, in the case of two of Dr. Pavy's patients, became 
reduced to less than 700 grammes per diem, while on a mixed diet 
it had amounted to from 6,000 to 9,000 grammes, and the urine 
diminished in quantity from 160 and 200 ounces to about 60 ounces 
in the twenty-four hours. 

309. New Qlycerine Sponsre Cake.— It occurred to me, some 
time since, that the bran, with eggs and glycerine, might be made 
into a form of sponge cake, and I tried some experiments with this 
view. Mr. Blatchley has lately succeeded in making for me a most 
excellent diabetic food of these ingredients. It is not only palatable, 
but really nice. When freshly made, the cakes are as soft as ordinary 
sponge cake. They may be dried, and will keep for any length of 
time. In the dry state they can be readily softened in soup, tea, or 
coflfee. They can be flavoured with lemon, or other flavour, according 
to taste. A similar kind of food can be made with savory gravy; and 
in cases where the digestive powers of the stomach are impaired, a 
few grains of pepsine can be added with advantage. Food made on 
a similar principle with ordinary flour, concentrated extract of meat, 
and pepsine, is valuable in many cases when the stomach is very 
weak and irritable. 

The sponge cakes are prepared by Mr. Blatchley, 362, Oxford 
Street. When fresh they cost 2s. 6d., and when dry 3s. 6d., per 
pound. They form by far the most palatable diabetic food I have 
ever tried. 

810. TVrannfactarers of Gluten Bread, &c., for Diabetic 
Patients. — The various substances required for diabetic patients 
may be obtained of the following firms, which are arranged 
alphabetically : — 

Van Abbott, G., and Co., Howford Buildings, 148^, Fenchurch 



258 TREATMENT OF DIABETES. 

Street, and 5, Princes Street, Cavendish Square — Gluten 

Bread — Toulouse Gluten Bread, &c. 
Bewley & Evans, 3 & 4, Lower Sackville Street, Dublin — Gluten 

Bread, &c. 
Bell, 338, Oxford Street— Gluten Bread, &c. 
Blatchley, E., 362, Oxford Street — Bran and Gluten — Bran and 

Gluten Cake and Biscuits — ^The Glycerine Sponge Cake. 
Bullock & Reynolds, 3, Hanover Street, W. 
Hill, W., 60 & 61, Bishopsgate Street, KC— Almond Cakes, 

Biscuits, and Rusks. 
GoUop, 149, Cheapside — Maker of Mills for Grinding Bran. 
Smith, Baker, Gower Street, N. — Bran Biscuits, &c 

311. "Wines.— Of wines containing little sugar, amontillado, 
mansanilla, and manilla, may be taken, and good claret may be recom- 
mended. Whisky or brandy are also admissible. Vichy, or other 
alkaline water may be taken in moderate quantity, but it is well to 
restrain the diabetic patient from taking too much fluid. Lime 
water has been recommended as well as potash and soda waters. 

312. Vegetables. — ^The best vegetables are cabbage, French 
beans, lettuce, and watercresses. Asparagus should not be taken, as, 
according to Dr.. Harley, when eaten in quantity, temporary diabetes 
may be induced. Potatoes and all vegetables containing much starch, 
and fruits, both fresh and dried, as they contain sugar, must not be 
eaten. 

818. ICedicines. — Various medicines have been prescribed in 
cases of diabetes, and there can be no doubt that benefit often 
results from the use of ordinary tonics, and the mineral acids are 
sometimes of service. Phosphoric acid allays the thirst. A very agree- 
able drink may be made as follows : — ^acid phosph. dil. two drachms, 
glycerine, half-an-ounce, water half-a-pint ; mix : a few tablespoonfuls 
of this may be taken occasionally during the day. Various bitter 
infusions, and citrate of potash and ammonia, sometimes appear to do 
good. Opium is with some a very favourite remedy, but in the 
cases in which it has been given the diet has been altered as well, 
so that, with regard to this and many other remedies, it is impossible 
to say how far the benefit results from the remedy, or is due to 
the diet. Of all the remedies I have tried, the old tincture of 



TREATMENT OF DIABETES. 259 

sesqui chloride of iron has, I think, been of the most use. I giTe 
from ten minims to half-a-drachm, two or three times a day, in 
infusion of quassia, and make the patient continue taking the 
medicine for months. Under its use, I have found in many cases, 
that the strength improves, and the patient has gained in weight. 
Cod-liver oil is of service in some cases. 

Sugar has been given in large quantity in diabetes, and, as 
would be supposed, has been found worse than useless. 

814. Alkalies have been given in diabetes without decided 
benefit. I have given large doses of liquor potassaB ( Jiij per diem) 
without any alteration in the quantity or density of the urine. 
Vichy water is a very favorite remedy with some, and this and other 
alkaline waters are exceedingly gratefol to the patient. For this 
reason they may always be ordered, but I doubt if any real effect 
is produced upon the disease by their use. Gunzler states that 
bicarbonate of soda reduces the quantity of sugar. 

316. Alcohol is said to increase the sugar, but moderate quan- 
tities of brandy or whiskey seem to be of service in some cases. I 
am accustomed to order two or three ounces of whiskey daily, if the 
patient is weak. I have never seen any bad effects resulting, and 
many cases have improved while taking this stimulant. 

816. Bexmet and Pepsin have been given in diabetes. Dr. 
James Gray ("Glasgow Medical Journal" Vol. IV.) states that, of 
twenty-eight persons treated by rennet, seven * completely recovered,' 
but they were also placed upon a restricted diet. Dr. Roberts tried 
rennet, but although the patient improved while taking it, he 
improved quite as rapidly before he commenced taking this remedy. 
C'Brit. Med. Journ.," Nov. 17th, 1860.) 

According to Leubuscher, the quantity of urea, chloride of sodium, 
and sugar, were increased by the administration of pepsin, and Dr. 
Parkes also found that this substance increased the sugar. On 
the contrary, in one case in which I tried it, benefit resulted, but 
then there was some dyspepsia, and I thought that the diet was 
imperfectly assimilated. I have not had an opportunity of trying 
the effect of pepsin in a very bad case of diabetes, but, in various 
conditions in which the digestive power of the stomach is impaired, 



260 TREATMENT OF DIABETES. 

either temporarily or permanently, I have used it with the greatest 
advantage. Beally good pepsin has not yet had a fair trial in this 



Many practitioners doubt the eflficacy of pepsin in any case, and 
some consider it perfectly useless. I believe that such conclusions 
have been arrived at from bad pepsin having been used. Some years 
agd (1856), I made some experiments in connection with the action of 
artificial digestive fluids, and found that, by the following simple 
method, a very powerful digestive powder, almost tasteless and in- 
odorous, could be readily obtained from the pig's stomach. The 
pepsin prepared according to the following method is more active 
than any of the other preparations now in use. I have used it very 
frequently during the last six years, and it is well known to many 
other practitioners. 

Preparation of Pepsin, — The mucous membrane of a perfectly 
fresh pig's stomach is carefully dissected from the muscular coat, and 
placed on a flat board. It is then cleansed with a sponge and a little 
water, and much of the mucus, remains of food, &c., carefully re- 
moved. With the back of a knife, or with an ivory paper-knife, the 
surface is scraped very hard, in order to press the glands and squeeze 
out their contents. The viscid mucus thus obtained contains the 
pure gastric juice, with much epithelium from the glands and surface 
of the mucous membrane. It is spread out upon a piece of glass, so 
as to form a very thin layer, which is dried at a temperature of 100° 
over hot water, or in vacuo over sulphuric acid. When dry it is 
scraped from the glass, powdered, and kept in a stoppered bottle. A 
good digestive fluid may be made as follows: — 

Of the powder 5 grains. 

Strong hydrochloric acid . . . .18 drops. 

Water 6 ounces. 

The fluid may be filtered easily, and forms a perfectly clear solution, 
very convenient for experiments on artificial digestion, or as a 
medicine. 

The pepsin may be taken in doses of from three to five grains 
made into a pill with a little glycerine, and taken about twenty 
minutes before a meal, with ten drops of dilute hydrochloric acid in 
a wine-glassful of water, or infusion of quassia; or the powder may 
be mixed with the salt taken with the meals, or sprinkled upon the 
meat or on bread and butter, as it is tasteless and inodorous. 



ALCAPTON LEUCINE. 261 

I have kept this pepsin in a well-stoppered bottle for three 
years without its active powers being in any way impaired. Four- 
fifths of a grain of this pepsin, with ten drops of diluted hydro- 
chloric acid and an ounce of water, dissolve 100 grains of hard- 
boiled white of egg. {^^ Archives of Medicine,''^ Vol I., pp. 269, 316.) 

It is prepared by Messrs. Bullock <fe Reynolds, 3, Hanover 
Street, W. It costs a shilling a drachm, which may be divided into 
fifteen or twenty doses. 

Alcapton. 

317. Alcapton. — Bodecker has found in the urine of a patient a 
substance which possesses many of the reactions of sugar. This is 
termed alcapton. It is of a pale yellow colour, and does not crystal- 
lise. It contains a large quantity of ammonia. It reduces copper, 
like sugar, but does not reduce oxide of bismuth, nor is fermentation 
excited in it by yeast. Urine containing it becomes of a brown 
colour upon exposure to the air, if an alkali be present, without the 
application of heat. This change occurs if potash be added. Sugar 
and potash change colour only when the solution is boiled. 

Alcapton was separated by Bodecker from the urine by the 
following process: — After precipitation with acetate of lead, the 
mixture was filtered, and the solution mixed with tribasic acetate of 
lead, avoiding excess. The precipitate was washed, suspended in 
water, and decomposed by sulphuretted hydrogen. The solution 
filtered fi:om the sulphuret of lead was evaporated to dryness over 
the water bath, and the residue extracted with ether. The alcapton 
remained after the ether had evaporated. (Bodecker: Zeitschrift. f. 
rat. Med. VII., 128; ''Ann. Ch, Pharm,;' Jan., 1861; Bowman's 
''Medical Chemistry,'' edited by Prof. Bloxam, p. 6J.) Alcapton 
was found in the urine of an infant by Dr. Johnson, his attention 
being called to it by the brown stains on the linen (quoted in Bow- 
man's "Med, Chem,,'' by Bloxam, p. 52). 

Leucine. 

318. Leucine (CiaHulNOO occasionally occurs as a deposit firom 
the urine ; but more generally it is held in solution, and can only 
be obtained by concentration of the fluid, when it crystallises out in 



262 LEUCINE. 

the form of EmaaJl spherules, which are composed of acicular crystals 
which radiate from a common centre. This substance has of late 
been found in many of the solids and fluids of the animal body. It is 
not very soluble in water (one part in twenty-seven), but more so in 
alcohol. It crystallises from aqueous solutions, for the most part in 
spherical masses, which exhibit a radiated arrangement. From 
alcohol, leucine is deposited in the form of pearly scales, somewhat 
resembling cholesterine ; but these are composed of small spherules. 
Dry leucine can be sublimed 'without change. Leucine has been 
found in the saliva, pancreatic juice, and in the pulmonary tissue of 
the ox (Clo6tta, ^^ Chemical Gazette,'' 1856, p. 61). Frerichs and 
Stadeler have detected leucine in the blood, urine, and bile of 
patients suffering from typhus, small-pox, and other exanthemata. 
Dr. Thudichum found leucine in the urine of a man whose liver 
yielded a large quantity of it {^^ Treatise on the Pathology of the 
Uriney' 1868). It was obtained by concentrating the urine. This 
substance is probably formed in the liver. In certain diseases, it is 
to be detected in very considerable quantity. Crystals of leucine 
may often be seen in sections of livers of patients who have died of 
jaundice. Frerichs has given several figures of leucine crystals in 
the liver, and also in the urine (^* Pathologisch-dnatomischer Atlas 
zur Leherhranhheiterty' von Dr. F. T. Frerichs, Braunschweig, 
1858). It is said to occur especially in the urine of patients 
suffering from acute yellow atrophy of the liver. I have detected 
leucine in the urine in cases of chronic wasting of the liver accom- 
panied with jaundice. 

No satisfactory tests for leucine are yet known. If it can be 
obtained pretty pure by repeated recrystallisation, the dry leucine 
may be sublimed. The sublimate, composed of aggregations of 
rhombic plates, could not be mistaken for anything else. Urate of 
soda and many other substances crystallise in spherical globes, like 
leucine. Crystals of this form, however, which are soluble in alcohol, 
and again crystallise in spherules from an aqueous solution, can hardly 
be anything but leucine. This substance cannot be recognised 
by the form of the crystals alone. 

819. On Obtainingr Crsrstals of Ijeuoine from the ITrizie.— 
The extractive matters often interfere with the crystallisation of the 
leucine from urine, and the concentrated extract often remains for 



TYROSINE. 263 

days ivithout undergoing any change. Frerichs {"Klinik der Leber- 
krankheiteny" Band I., s. 221) recommends that the concentrated 
urine should be digested for some time with cold absolute alcohol. 
By this means, the extractive matters are gradually dissolved out. 
The residue is then to be treated with boiling spirits of wine; and 
leucine crystallises out as this solution cools. It may be purified by 
recrystallisation. The extractive matter may be in great part 
separated by precipitation with acetate of lead. If much leucine is 
present it crystallises if the urine be concentrated. . Crystals of 
leucine are represented in Plate XIV., Figs. 69, 70. The crystals at 
a, were crystallised from water. The rest were obtained from an 
alcoholic solution. 

Tyrosine. 

320. Tyrosine (CiaHuNOe) has been detected in the urine of 
typhus fever by Frerichs and Stadeler. Like leucine, it is probably 
produced in the liver. It has been detected in this organ by Frerichs, 
Dr. Thudichum, and many other observers. It has been extracted 
from several animal fluids. Tyrosine crystallises in long white 
needles, and is very slightly soluble in cold water. Crystals of 
tyrosine are represented in Plate XIV., Fig. 71. It is dissolved by 
boiling water, alcohol, ether, the mineral acids, and alkalies. It may 
be prepared by boiling horn, feathers, or hair, with sulphuric acid, 
for forty hours. The dark brown liquid is to be made alkaline with 
milk of lime, warmed, and then filtered. Sulphuric acid is added to 
neutralisation, and crystals are deposited upon evaporating the 
liquid. A very delicate test for this substance has been proposed by 
Hoffman. A solution of nitrate of protoxide of mercury, nearly 
neutral, is to be added to the solution suspected to contain tyrosine. 
If this body be present, a reddish precipitate is produced, and the 
supernatant fluid is of a very dark rose colour. Frerichs' tests for 
tyrosine are as follows: — The matter supposed to be tyrosine is 
mixed with sulphuric acid in a small capsule. After the lapse of 
half an hour water is added. The solution is then boiled, and excess 
of carbonate of lime added. To the filtered solution a few drops of 
a solution of perchloride of iron which is free from acid is added. A 
dark purple colour is produced if tyrosine is present. In order to 
obtain tyrosine from urine it is necessary to add a solution of acetate 



264 mosiTE. 

of lead until a precipitate is no longer produced. Sulphuretted 
hydrogen is passed through the filtered liquid. The sulphuret of 
lead heing separated hy filtration, the clear solution may be concen- 
trated by evaporation, when tyrosine, if present, will crystallise out. 
Tyrosine crystallises in long white needles, which are aggregated to 
form brush-like masses. De la Rue found tyrosine in the cochineal 
insect. This is doubtless one of the substances resulting from the 
disintegration of albuminous substances. I have found it in con- 
siderable quantity in urine which contained much uric acid, and 
had been left to stand in a warm place for many weeks. 

Leucine and tyrosine were detected by Dr. Harley in the urine 
of a dog four days after dog's bile had been injected under the 
skin. ("On Jaundice,'' p. 96.) 

Inositb. 

821. Inosite (CuHu80u+4HO) was discovered by Scherer in the 
juice of muscle, after the creatine and creatinine had been separated. 
It is termed muscle-sugar, and may be obtained in the form of 
colourless prismatic crystals, which are efllorescent. Crystals of 
Inosite are represented in Plate XI., Fig. 60. Inosite does not 
reduce the oxide of copper to the state of suboxide, as is the case 
with diabetic sugar and grape-sugar. It tastes sweet, and has the 
same composition as the latter substance. Inosite may be detected 
by evaporation nearly to dryness in a platinum basin, when, if a 
little ammonia and chloride of calcium be added, a rose colour is 
produced, especially if the mixture be again concentrated by 
evaporation. 

CloStta has found inosite in the urine in Bright's disease, but has 
failed to detect it in the healthy secretion. He has discovered it in 
the lungs, liver, spleen, and kidneys. The lungs also contain traces 
of uric acid, taurine, and leucine. M. Hohl has lately recorded a 
case of diabetes in which a large quantity of inosite was obtained 
from the urine (^^ Gazette Hebd. de MM. et de Chir.," 1859, p. 221; 
^^ Journal de la Physiologie,'' No. vL, p. 344). In this case, the pro- 
portion of sugar gradually diminished, and at the same time the 
quantity of urea excreted became less, while the inosite gradually 
increased in amount until upwards of three hundred grains of this 
substance were passed in the twenty-four hours. This observation is 
one of great interest in connection with the pathology of diabetes. 



T,EUCIN&-TYROSINE-CYSTINE. 



Platk XTV. 



"&' 



Fig. 69. 






F\sr. 70. 










§ 319 



ng. 71. 





§ 319 



Fig. 71*. 




§320 



ToloAe'P*^^*'^'^* 






I 



1 



ACETONE — CTSTINE — ^TAURINE. 265 



Acetone. 



822. Acetone (CaH«Oa).— Dr. Fetters, at the suggestion of Dr. 
Lercli, of Prague, sought for acetone in the urine of a case of 
diabetes, and discovered it both in the blood and urine (Viertel- 
jahrsch, fiir die PracU Heilkunde, Prag, 1857, Vol LV., p. 81). 
The peculiar smell of diabetic urine is to be attributed to the 
presence of acetone, according to this observer. 

Cystine. 

823. Cystine (CuHuKaS^O,) is found in a state of solution in the 
urine in some cases, although it more usually occurs as a deposit. 
We shall, therefore, consider it more particularly under the head of 
urinary deposits. Julius Miiller l^Archiv, der Pkarmacie") obtained 
some urine from a boy 6J years of age, which contained cystine in 
solution. The urine was alkaline. The cystine was precipitated 
in the crystalline form by the addition of excess of acetic acid. 
Thoel mentions the occurrence of cystine in the urine of many 
members of the same family (Liebig and Wohler's ^^Annalen" 1856). 
Crystals of cystine are represented in Plate X., Figs. 1, 2, 3, 4, of 
^* Illustrations of Urine^ Urinary Deposits, and Calculi f and in 
Plate XIV., Fig. 71* of this work. 

Taurine (P^^^O^ has been found in the urine of jaundice. 

Allantoin (CsHeNA) has never been detected in human urine, 
but it was present in the urine of a dog into whose lungs oil had 
been injected by Frerichs and Stadeler. It may, perhaps, exist in 
the urine of young children (Parkes). It is always present in the 
urine of calves while sucking, but afterwards it is replaced by 
hippuric acid. 

GKumin, Sarkosin, and Xynurenic Aoid (the peculiar acid of 
the urine of the dog), have never been positively detected in the 
urine of man (Parkes). 

Hypoxanthin (CiMJSSfii), or Sarkine, is found with Xanthine 
(§ 401). It has been detected by Scherer in the urine in Leucocy- 
themia. 



266 IMPOBTANCE OF SGIENTIFIG BESEABCH. 

I have ventured to occupy some time in the consideration of the 
characters of certain substances the presence of which in urine has 
only very recently been demonstrated. Probably, when the various 
materials removed in this excretion shall have been more thoroughly 
investigated, and when we know more relating to the precise condi- 
tions under which they are formed in the animal economy, the 
treatment of many diseases will be placed on a sounder basis, and 
we shall be able to relieve sufferings and prevent the progress of 
morbid changes over which we have now very little control. It is 
true, there are many who consider all this minute scrutiny and 
scientific investigation as useless, or at least unnecessary and unprac- 
tical. This is a state of mind which it is difficult to understand ; 
for it seems obvious the more minutely our investigation of diseased 
processes is carried out, the more we shall know about them, and the 
better able shall we be to suggest plans of treatment to combat the 
abnormal changes. That scientific work will ultimately lead to great 
practical results in treatment is certain; and every one must feel that 
any amount of time devoted to original research is most usefully 
and advantageously spent. 



267 



CHAPTEE XIII, 



Urine in Disease. 1. Substances floating on the Surface 
OF THE Urine, or diffused through it, but not forming 
A visible Deposit. Thin PeUicle formed upon the Surface 
of Urine — Opalescent Urine — Opalescence produced bi/ Vibri^ 
ones — Milk in Urine, Different States in which Fatty 
Matters occur in Urine. Chylous Urine — Mr. CuUtfs 
Case — Dr, Bence Jonei Case — Dr, Waters^ Case — Dr, 
Priestly* s Case—Dr, Carter^ s Cases — Analyses of the Urine 
— Microscopical Charajcters of the Deposit — Of the Treats 
ment of Cases of Chylous Urine — Of the Nature of Chylous 
Urine — Composition of Fatty Matter passed in Cases of 
Fatty Degeneration of the Kidney — Cholesterine in Urine — 
Cholesterine said to be obtained from the Urine in other 
Diseases — Kiestein. Other Forms in which Fatty Matter 
occurs in Urine. Urostealith — Fluid Yellow Fat — Fatty 
Matter in JRMits^ Urine — Erroneous Observations connected 
with the Presence of Fatty Matter in Urine, 

824. Thin Pellicle formed upon the Snxftioe of Urine 

Several different substances are found from time to time floating on 
the surface of urine ; but, for the most part, these are merely buoyed 
up by a thin pellicle, which is probably formed by the action of the 
air on the urine, leading to the decomposition of some of its consti- 
tuents. This often causes the precipitation of the phosphates mixed 
with organic matter in the form of a thin pellicle. Triple phosphate 
is also deposited in the pellicle, in a crystalline form, some of the 
crystals being exceedingly minute, but still exhibiting their well 
known characters. A similar pellicle may always be formed, if urine 
be somewhat concentrated by evaporation; but in this case a large 

N 3 



268 OPALESCENT URINE. 

quantity of urate of soda is entangled in it. The urate crystallises 
in the form of small spherical masses, from all sides of which little 
spicules project (Plate XIX., Fig. 92). 

Fatty matter is often found floating upon the surface of urine, 
especially when it has fallen in accidentally. One form of fatty 
matter has been described under the name of kiestein, and this it 
has been said is constantly present in the urine of pregnant women. 

Urates occasionally accumulate upon the surface of urine, but 
present nothing peculiar for remark. 

825. Opalesoent Urine. — The turbidity or opalescence of urine 
is most frequently due to the presence of urates in an exceedingly 
minute state of division. The precipitate may be so fine and so light 
that it will not sink to the bottom and leave a clear supernatant 
fluid. The urine is perfectly clear when passed, but becomes turbid 
afterwards. Upon the application of a gentle heat, the turbidity is 
instantly removed. In urine of high specific gravity, many sub- 
stances are held in suspension which would form a deposit in fluids 
of the usual density. It is not uncommon to meet with pus or blood 
thus diffused through the urine. If mucus be present in large 
proportion, many substances which usually form deposits will be 
buoyed up as it were, and evenly diffused through the fluid, although 
generally these substances subside more or less. 

Opalescence prodticed by Vihriones, Some specimens of urine 
become decomposed very soon after they have been passed; others 
are voided in a state of incipient decomposition. Such specimens 
are found turbid, and look as if they had been mixed with a very 
small quantity of milk. Upon microscopical examination, it will be 
found that this turbidity depends entirely upon multitudes of some 
of the lowest organisms, consisting of different forms of fungi and 
other little elongated bodies termed vibriones, which are considered 
by some authorities to be animals, while others class them with 
vegetables. There can be little doubt as to their vegetable nature. 

Milh is often added to urine, for the purpose of deceiving us, and 
is of course diffused through the fluid, the degree of opalescence 
varying according to the quantity of milk added. Milk can always 
be detected upon microscopical examination by the presence of the 
numerous oil-globules, and by the circumstance of the milky fluid 
becoming quite clear after agitation with a little ether and a few 



FATTY MATTER IN URINE. 269 

drops of acetic acid or carbonate of potash, which will dissolve the 
envelopes of casein around the globules, and thus the oily matter 
becomes exposed to the solvent action of the ether. By the addition 
of a little acetic acid, the casein of the milk is precipitated. 

It is astonishing with what pertinacity some patients adhere to 
the statement that the milk which we detect has really been passed 
in the urine, as they state, although its true nature has been 
demonstrated most conclusively. A case was brought under my 
notice, some time since, of a young girl, who convinced all her friends 
that she passed more than a pint of milk and water a day in the 
form of tears ! The fluid was proved to be milk, and in it were found 
epithelial cells from the mouth. The patient admitted afterwards 
that she had imposed upon her friends. 

Oil, it must be remembered, is often found in urine in the form of 
free globules, especially after the use of an oiled catheter. Butter 
and other fatty matters sometimes fall into the urine accidentally. 
{See also § 87.) 

Fatty Matter in Urine. 

826. Different States in which Fatty flatter occurs in 
"Urine.— The different conditions in which fatty matter has been 
found in urine, may be summed up under the following heads: — 

1. In a molecular state, as in chylous urine. 

2. In the form of globules, as when oil, fatty matter, or milk, have 
been added to urine. 

3. In the form of globules (a), free in the deposit (ft), enclosed in 
cells (fat-cell), or (c) entangled in casts. 

4. Dissolved in small quantity by other constituents, so that its 
presence can only be detected by chemical examination. 

5. In the form of concretions (urostealith, as described in one 
solitary case by Heller). 

6. In a fluid state, of which two cases are reported by Dr. C. 
Mettenheimer. 

Chylous Urine. 

327. Cliylons Urine. — The most important substance which 
gives to urine an opalescent appearance, and at the same time 
causes it to resemble milk, is fatty matter in a very minute state of 



270 CHYLOUS URINE. 

diyision — ^in a molecular state, as it is tenned. Sach urine, under 
the microscope, is seen to contain a considerable quantity of the most 
minute particles, which exhibit molecular movements, and a few 
small granular cells very much like white blood or chyle corpuscles 
are often observed (See Plate XV., Fig. 72). The minute particles are 
not altered by a moderate heat, but are dissolved in great measure, 
though often not entirely, if the urine be agitated with ether. 
Urine possessing these characters is termed chylous urine. Chylous 
urine often contains a little blood which produces a pinkish hue. 
Cases of chylous urine are very seldom met with in this country, but 
they are comparatively common in Brazil, Cuba, the West Indies, 
the Mauritius and India. 

The following interesting case occurred in the practice of my 
friend Mr. Cubitt of Stroud, to whom I am indebted for the notes, 
and also for the specimens of urine which I analysed. 

828. KEr. Oubitt's Case of Chylous Urine.— ''Mrs. S., aged 50, 
native of Norfolk, in which county she has always resided, has been 
married twenty-nine years, and has had five children, the last of 
whom died in its second year. The youngest now living is 20. The 
catamenia ceased at 43. 

"Till within the last four years, she has usually enjoyed good 
health, but at that time had a severe attack of influenza. She 
continued more or less out of health during the six or nine following 
months, and soon after this period her urine assumed a milky 
appearance, which character it has retained up to the present time 
(November, 1849), except at intervals of unfrequent occurrence and 
of short duration. The disorder would seem to have been gradually 
progressive, as the urine, which was at first only turbid and opa- 
lescent, has become by degrees more and more opaque, so that when 
I saw it, the unassisted eye could not distinguish between it and 
milk; moreover, after the lapse of a few days, a rich kind of cream 
rises to the surface. It is almost entirely free from any urinous 
odour, and has a faint, sweetish smell, something resembling that of 
ripe apples. In the mean time, the general health has been more 
and more failing, and the digestive ftinctions imperfectly performed; 
the patient has complained of loss of appetite, pain at the epigas- 
trium after eating, slight headache with nausea, palpitations, and 
other dyspeptic symptoms. She has been losing flesh, sufiers from 



CHYLOUS URINE. 271 

pain in the back and loins without tenderness, from aching of the 
limbs, incapability of exertion, and other evidences of general 
debility; but still when the duration of the disease is taken into 
account, the general health may, upon the whole, be said to have 
suffered little. She states that, throughout the affection, fatigue, 
whether of mind or body, unusual exertion, excitement, late hours, 
distress, anxiety, immediately render the milky character of the 
urine more marked. She has been under the care of several medical 
men, as well as of some professed quacks (none of whom have ever 
examined the urine), without benefit; nevertheless, she has found 
that, for the time, brandy and isinglass, or compound spirits of 
lavender, have never failed to clear the urine, but without at all 
improving the general health. She seems to derive temporary relief 
from all kind of stimulants. Occasionally, and without any appa- 
rent cause, the urine reassumes its ordinary appearance, but this is 
of rare occurrence, and its duration never exceeds two or three days. 
At no one time has she passed milky urine during the day. It is 
only the urine passed in the morning, after the night's sleep, which 
has ever presented a milky character. Occasionally, this urine 
settles down into a tremulous jelly, which takes the shape of the 
containing vessel, and more than once this spontaneous coagulation 
has taken place within the bladder itself; and in consequence of the 
impaction of small masses in the urethra, the patient has suffered 
from temporary retention of urine. She has tried various kinds of 
diet, but without any visible effect upon the urine. The quantity 
secreted appears normal, and there is no unusual frequency of mic- 
turition. The appetite has never been inordinate, or the thirst 
unnatural ; the bowels are inclined to be costive. There is nothing 
remarkable about the state of the skin. She has suffered a good deal 
from pain in the back and loins, but there is no tenderness in this 
locality, and the uneasiness seems to depend upon exertion, and 
appears to be connected with general debility. There has never 
been any dropsy, and she has suffered from no cardiac or pulmonary 
symptoms, but such as may be accounted for by the dyspepsia; but 
I have not had an opportunity of examining the chest. She has 
never had severe headache, vertigo, vomiting, or other cerebral 
symptoms. Has never had rheumatism, fever, or any inflammatory 
attack, has not been salivated, and has no reason to suppose she has 
suffered from exposure to cold. At the time when I saw her, the 



272 ANALYSES OF 

tongae was slightly furred, pulse 70, small and soft, respiration 20, 
and the skin cool ; but there was a haggard appearance about the 
countenance, and a dark circle around the eyes, with slight bagging 
of the skin in this situation." 

Mr. Cubitt inquired as to this patient's state in April, 1857, and 
informed me that occasionally she passed chylous urine, but only for 
a short time. The symptoms seem to have become less marked. 
She has been taking no medicine, and latterly has been in better 
general health than for several years past. 

820. Anal3nBe8 of Chylous Urine.— The first specimen of urine 
was passed in the morning (Analysis 58). It was perfectly fluid, 
and had all the appearance of fresh milk. It had neither a urinous 
smell nor taste. Upon the addition of an equal volume of ether it 
became perfectly clear ; but when the ether was allowed to evaporate 
by the application of a gentle heat, the fatty matter could be again 
diffused, by agitation, through the urine, which regained its milky 
appearance, although it appeared rather more transparent than 
before the addition of the ether. Upon examination, however, by 
the microscope, instead of the minute granules visible in the first 
instance, numerous large and weU-deJined oil-globules were observed. 

Specific gravity, 1013. Reaction, neutral. 

A little of the urine was evaporated to dryness. The dry residue 
was very greasy to the touch. It was treated with ether ; and, upon 
evaporating the ethereal solution, a considerable quantity of hard 
and colourless fat was obtained. 

Analysis 58. 

The urine was found to contain in 1000 parts- 
Water 947-4 

Solid matter 52*6 

Urea 773 

Albumen 13-00 

Extractive matter with uric acid . . . 11-66 
Fat insoluble in hot and cold alcohol, but 

soluble in ether 9*20 \ 

Fat insoluble in cold alcohol . . . 2*70 |- 1 3'9 

Fat soluble in cold alcohol .... 2-00 j 
Alkaline sulphates and chlorides . . . 1-65 

Phosphates 4*66 



CHYLOUS URINE. 273 

The second specimen (Analysis 59) was passed during the same 
day. It was slightly turbid, but contained a mere trace of deposit, 
consisting of a little epithelium, with a few cells larger than lymph 
corpuscles, and a few small cells, probably minute fungi. Not the 
slightest precipitate was produced by the application of heat, or by 
the addition of nitric acid. 

Specific gravity, 1010. Reaction, very slightly acid. 



Analysis 59. 

In 1000 parts it contained — 

Water 978-8 

Solid matter 21*2 

Urea 695 

Uric Acid 15 

Extractive matter 7*31 

Fatty matter 

Alkaline sulphates and chlorides . . . 5*34 

Alkaline phosphates 1*45 ) 

Earthy phosphates '15 J 

The presence of so large a proportion of fatty matter, perhaps, 
combined with the albumen (13*9 grains) in the first specimen, and 
its complete absence in the second, which was passed only a few 
hours afterwards, is very interesting, and bears upon the pathology 
of this strange condition. 

The proportion of the constituents in 100 grains of the solid 
matter of these two specimens of urine, is given in the following 
table. 60 is the chylous, 61 the clear specimen : — 





60 


61 


Solid matter .... 


100-00 


100-00 


Urea 


14-69 


32-78 


Albumen .... 


24-71 


— 


Extractive matter, uric acid . 


22-17 


35-18 


Fatty matter 


26-43 


— 


Alkaline sulphates and chlorides 


3-14 


25-18 


Phosphates. 


8-86 


7-54 



N 5 



274 CHARACTERS OF THE DEPOSIT OF 

880. MioroBoopioal Oharaoters of the Depo«it.^The slight 
deposit which formed after the chylous urine had been allowed to 
stand for some time in a conical glass vessel, consisted of a small 
quantity of vesical epithelium, and some small slightly granular 
circular cells resembling chyle or lymph corpuscles. 

No oil-globules could be detected upon the sur^e of the urine 
or amongst the deposit, and the fatty matter, which was equally 
diffused throughout, was in a molecular or granular form. By 
examining the urine with the highest powers, only very minute 
granules could be detected. These exhibited molecular movements. 
Indeed, it may be said that the microscopical characters of this 
urine closely resembled those of chyle. (Plate XV., Fig. 72.) 

Only a few of the granular cells could be discovered in the clear 
specimen, in which there was scarcely any visible deposit. 

In a case which occurred in the practice of Mr. Gossett, and 
which is related by Dr. Golding Bird, an alternation in the character 
of the urine similar to that noticed in the present case, occurred. 
As in this case, the urine which was passed in the morning was 
chylous, while that secreted some hours afterwards was clear , pale, 
and transparent. The clear specimens, however, contained albumen. 
The chylous specimen which I examined did not coagulate spon- 
taneously, as often occurs in these cases. In the case reported by 
Dr. Bence Jones, specimens of urine were frequently passed which 
were perfectly clear. 

L'H^retier, and the late Dr. Franz Simon, of Berlin, state that 
these specimens of milky-looking urine contain oil-globules; but the 
greater number of authors who have met with such cases have failed 
to detect oil-globules in the urine. In the instance under conside- 
ration they were certainly absent, and the fatty matter existed in a 
molecular form only. In Dr. Bence Jones' case, oU-globules were 
found in one or two instances; but in other specimens the fatty 
matter was present in a molecular state. Dr. Waters states that 
oil-globules were present in the urine in a case he had under his 
care, and that the urine contained mucus and pus-corpuscles. 

In true cases of chylous urine, the fatty matter, in a molecular 
state, seems to escape at once into the urine ; while in cases of fatty 
degeneration of the kidney, in which actual globules are observed, 
the fatty matter exists in the interior of the cells, where it remains 
a sufficient time to become converted into distinct oil-globules. 



CHYLOUS URINE. 275 

Globules thus formed may afterwards become separated from eaxsb 
other, and may appear in the urine as free oil-globules. Such oU- 
glohules make their appearance in all cells which have been kept 
for some time in * preservative fluids.' The change in question is 
unfortunately too familiar to microscopists. It would seem to show 
that the oil-globules result from the decomposition of matter which, 
under the conditions present in the healthy living body, would be 
resolved into perfectly soluble constituents, and it is not improbable 
that when this change occurs in cells in the living body, it is due to 
diminished activity of the chemical changes, and especially to 
diminished oxidation. 

After chylous urine has been allowed to stand for some time, the 
granular fatty matter may become aggregated in masses, so as to 
form distinct oil-globules. 

881. Br. Bence Jones' Oases.— -In a case of albuminous and 
fatty urine, reported by Dr. Bence Jones (" Medico-Chirurgicdl 
TransactionSj^^ Vol. XXXIII.), oil-globules and streaks of oil were de- 
tected upon the surface of the urine which was passed in the morning, 
by microscopical examination. In two other specimens passed later 
in the day, fatty matter in a molecular form, but no oil-globules, was 
discovered. Upon standing, a coagulum formed in the urine. These 
specimens contained about 50 grains of solid matter in 1000 of urine. 
The patient was a Scotchman, aged 32. His work was hard, and he 
was subject to privations. The urine was first observed to be thick 
and white about CJhristmas, 1848 ; and at this time, the chief symp- 
tom from which he suffered, was acute pain in the loins. 

Lehmann is, as far as I know, the only observer who states that 
chylous urine never owes its opacity to fat (" Physiological Chem- 
istry,^^ Vol. III., p. 544). I have now seen and heard of several 
cases, and in every one the opacity was due to fatty matter. Autho- 
rities generally are quite agreed upon this point ; but some state that 
the fat is sometimes in the form of globules. In the cases I have 
seen, it was in a molecular state only. 

The following are two analyses of the urine in Dr. Bence Jones' 
case. The first was made on October 19th, and the second was 
passed some time afterwards, on the same day on which the patient 
was bled. 



276 



CHYLOUS URINE. 



Analyses, 



62 


63 


955-58 


943-13 


44-42 


66-87 


14-03 


13-95 


13-26 


24-06 


8-37 


7-46 


8-01 


10-80 


•75 


•60 



Water . 
Solid matter . 

Albumen 
Urea . 
Fatty matter 
Saline residue 
Loss . 



The chylous urine contained blood-corpuscles. The serum of the 
blood was not milky, but the blood contained in 1000 parts 240*03 
of solid residue, which contained of fatty matter '62 ; fibrine, 2-63; 
blood-globules, 159*3; solids of serum, 78*1. 

Dr. Bence Jones showed, in some valuable experiments on this 
case, that during complete rest, albumen was not passed. (" PhU, 
Trans.;' 1850.) 

The urine was not chylous from February 14th, 1850, to October 
4th, 1851, when it was again slightly chylous. The beneficial change 
was entirely attributable to ^dlic acid. At first, twenty grains 
three times a day were given, but this was afterwards diminished. 

Dr. Bence Jones mentions another case of a gentleman, aged 40, 
who passed the greater part of his life in the West Indies. The 
chylous condition of the urine was increased both by mental and 
bodily exertion. The urine was sometimes clear for several days 
together, sometimes white after dinner, and clear all the rest of the 
day. It was more frequently chylous after animal than after vege- 
table food. 

332. Dr. Waters' Case. — Dr. Waters, of Liverpool {"Medico- 
Ghirurgical Transactions^' Vol. XLV., for 1862), reports the case 
of a young seaman, a native of Bermuda, in whom retention of the 
urine was caused by the coagulation of chylous urine within the 
bladder. The urine had the usual characters of chylous urine, but 
coagulated into a tremulous mass exactly resembling hlanomange. 
The urine contained blood-corpuscles. Analysis 64 shows the com- 
position of the urine in Dr. Waters' case of chylous urine. It was 
made by Dr. Baker Edwards, of Liverpool. Specific gravity, 1012. 



CHYLOUS URINE. 277 

Analysis 64. 

Water 967-3 

Solid matter 32-7 

Urea 6*0 

Albumen, with traces of uric acid . . . 6*0 

Fat 9-9 

Vesical mucus 4*5 

Animal extractive 4*1 

Fixed alkaline salts 2*0 

Earthy salts -2 

383. Dr. Priestley's OaBe. — The patient was a boy who was 
only 11 years of age. {^^ Medical Times and Gazette,'' April 18th, 
1857.) He was born at the Cape of Good Hope, and was taken as a 
child to the Isle of France, and while there had frequent attacks of 
hsBmaturia and chylous urine. The attacks came on at intervals of 
weeks or months. He was placed, in the autumn of 1855, under the 
care of Dr. Simpson, of Edinburgh. Various plans of treatment 
were tried in vain. He was confined to the house, and passed as 
much as from fifty to fifty-five ounces of chylous urine daily. He gra- 
dually became weaker, and died apparently from asthenia. A fort- 
night before death, the urine lost its milky appearance, and the feet 
became oedematous. Every tissue appeared bloodless, and there was 
considerable emaciation. The kidneys were pale, rather larger than 
natural. Throughout the greater part of both kidneys the epithe- 
lium was found to contain numerous oil-globules. Dr. Priestley 
suggests the possibility that this case of chylous urine may have been 
associated with Bright's disease. 

834. Dr. Carter's Oases.— The observations of Dr. Garter 
{'^ Medico-Chirurgical Transactions '' for 1862, Vol. XLV.) are 
strongly in favour of the view that chyle obtains direct entrance into 
some part of the urinary channels. In three cases reported by him, 
there was accumulation in the lymphatics. In the first the chyle 
was occasionally discharged firom the cutaneous surface, the urine 
being unaffected. 

The opening in the lymphatic vessel, from which the chyle 
escaped, was situated a few inches below Poupart's ligament, and 
sometimes a pint could be collected in a day. 



278 THE TREATMENT 

In the second case there was an external discharge of chyle, and 
the urine was frequently chylous. The third was a case of chylous 
urine without any external discharge of chyle. 

These cases prove the existence of a dilated condition of the 
lymphatic vessels. The dilatation clearly extending as high as the 
thoracic duct, thus allowing the chyle to pass from this tube into the 
lymphatics. In such a case the tube would be stretched so as to 
render the valves useless. 

Of the Treatment of Chylous Ubhtb. 

886. Of the Treatment of Oa4Bes of Chylous TXxine. — Various 
plans of treatment have been tried in cases of chylous urine, but 
without very satisfactory results. Astringents have proved useful in 
many instances ; and in one of Dr. Bence Jones' cases, the pressure 
of a tight belt "relieved the pain, and rendered the urine slightly 
less chylous." 

Dr. Prout found that in some of his cases temporary relief 
resulted from the use of the mineral acids and astringents, as alum 
and acetate of lead. Opium also arrested some of the symptoms for 
a while. Dr. Bence Jones has tried a variety of remedies, but the 
greatest advantage seems to have been derived from the use of 
astringents. Tannic acid, acetate of lead, and nitrate of silver, were 
employed. Matico afforded some relief, but the most valuable 
remedy in Dr. Bence Jones' hands was gallic acid. Its good effects 
were probably due to its astringent properties, and not to any specific 
action. The chylous character of the urine and the albumen 
disappeared two days after the commencement of the use of this 
drug; and in one case the patient seems to have been cured by its 
long continued use. (For the results of a daily examination of the 
urine for some weeks while the patient was on gallic acid, see '^Phil. 
Trans,,'' 1860.) 

In Dr. Priestley's case, the gallic acid caused such nausea that it 
was considered expedient to abandon its use. 

Gallic acid was also tried by Dr. Goodwin of Norwich, in a case 
which came under his care. He says — "Gallic acid appeared to 
exert great influence in restraining the milky appearance of the 
urine. The patient took it for about nine months in 1855 and 1856 ; 
and I found his water perfectly normal in colour after six months 



OP CHYLOUS UEINE. 279 

steady use of it in doses of half a drachm three times a day. He 
then discontinued its use, and went to work. In four or five days, 
the same milky appearance presented itself, and was again removed 
hy taking the gallic acid. He could at any time render the urine 
nearly normal in appearance by taking this drug; but it was 
necessary to avoid hard work. He only complained of occasional 
dimness of sight and deafness; but it was not easy to make out to 
what cause these symptoms were due. He left off attending the 
hospital in September last, when my note is as follows : — Has not 
had any gallic acid for three weeks, and the urine is now slightly 
opaline in appearance. Specific gravity, 1010; the temperature of 
air was about 50°. He passes seven pints and a half daily on the 
average. It does not coagulate with heat or nitric acid, or both 
combined.'* Dr. Goodwin has not been able to ascertain anything of 
the further history of the case. 

In Dr. Waters' case gallic add was given in doses commencing 
at 30 grains a day, gradually increased to 135 grains a day, and then 
gradually reduced. The patient was under treatment less than nine 
weeks and got quite well. His weight increased from 8 stone 6 lbs , 
to 10 stone 6 lbs. Four months after his discharge firom the hospital 
he continued in good health. There was no albumen or fatty matter 
in the urine. 

Op the Nature op Chylous Ueinb. 

886. Of Cases of Cbylous Urine. — ^The very large quantity of 
fatty matter present in the first specimen of urine (Analysis 58), and 
its total absence in the urine passed only a few hours afterwards 
(Analysis 59), is remarkable in Mr. Cubitt's case, and confirms the 
conclusions which previous observers have arrived at with reference 
to this condition; viz., that the &tty matter appears in largest 
quantity after the absorption of chyle ; although in Dr. Bence Jones' 
case it did not appear to be associated with any fatty condition of 
the blood. In Mr. Cubitt's case, we may, I think, conclude that 
there is no organic disease of the kidneys. First, from the absence 
of any symptoms ; secondly, from the microscopical characters of the 
deposit ; and, thirdly, from the feet that albumen was only present 
when the urine contained the fatty matter. 

Many of the patients whose cases are recorded, have suffered from 



280 OF THE NATURE OP 

severe pain in the region of the kidneys ; but this may be accounted 
for by general debility, associated with this condition of urine, as 
well as on the supposition of the existence of organic disease of the 
kidneys. Indeed, the pain referred to in this locality, seems to 
partake more of the character of muscular pain than of pain seated 
in the kidneys themselves. 

No lesion likely to account for the production of the chylous 
urine has been met with in the post-mortem examinations of the 
cases of this condition which have been made; and most observers 
consider that the chylous condition of the urine does not depend 
upon a morbid state of the kidneys. Dr. Elliotson, on the other 
hand, inclines to the view that the kidneys are to be regarded 
as the seat of the aflfection. He gives the history of a very 
interesting case in the "Medical Times and Gazette^^ for September 
19th, 1867. 

Dr. Waters, grounding his conclusions upon the apparent effects 
of treatment in one case, considers that the disease depends upon " A 
relaxed condition of the capillaries of the kidneys." He thinks that 
the fibrin, albumen, fat, and blood-corpuscles, simply filter away 
from the blood-vessels. The results of the two analyses recorded 
on pages 272, 273, are, however, quite inexplicable upon such a view. 

Dr. Carter has remarked, that in some analyses — as, for example, 
in mine already referred to (p. 272) — the relative proportion of 
albumen and fatty matter precisely accords with that in chyle, as 
shown in the following analyses : — 

Bees^ Analysis of Chyle. My Analysis of Chylous Urine. 
Per 1000. Per 1000. 

Fatty matter . 36*01 . . . . 13-9 

Albuminous matter 35' 16 . . . . 13*0 

In both the proportions are nearly equal, but the chyle varies 
somewhat in composition, there being two parts of albumen to one 
of fatty matter. Dr. Bence Jones' analysis of chylous urine shows a 
similar relation existing between the fatty and albuminous matters 
present. 

I have long suspected that the chyle passed into the urinary tract 
by a course more direct than was usually supposed, and the two 
concluding paragraphs which are left, with the exception of the 
words in brackets, as in the first edition of this work, clearly show 



CHYLOUS URINE. 281 

that I considered it important to search for a direct communication 
between the lacteal vessels and the urinary tract. Dr. Carter 
seems to have misunderstood my observation, that the "chylous 
character of the urine was intimately associated with the absorp- 
tion of chyle." The meaning I intended to convey was, that, 
after chyle had been undergoing absorption by the lacteah of the 
intestine, the chylous state of the urine was observed in some of the 
cases recorded. 

The cases of Dr. Carter are exceedingly important, and bear, in 
a most interesting manner, upon the pathology of chylous urine. 
There remains, however, the fkct to be demonstrated, that coloured 
fluid injected into the thoracic duct will pass into the pelvis of the 
kidney, ureters or bladder, in this disease. Post-mortems occur so 
rarely in this country, that it may be long before an opportunity of 
making the experiment offers itself. 

Upon reviewing the chief points in these and other cases, one is 
led to conclude that the condition does not depend upon any 
permanent morbid change in the secreting structure of the kidney, 
and that the chylous character of the urine is intimately connected 
with the absorption of chyle (by the lacteals ramifying on the 
intestines). The debility and emaciation show that the fatty 
matter, albumen, and other nutritive substances, are diverted from 
their proper course, and removed in the urine, instead of being 
appropriated to the nutrition of the system. Whether these 
materials, are separated from the blood by the kidneys, or find 
their way to these organs by some more direct course, cannot now 
be decided. 

I trust that practitioners who have opportunities of examining 
many of these cases in the West Indies, will afford us assistance in 
endeavouring to ascertain the nature of this curious condition. 
Careful reports of the most marked cases are much to be desired. 
In post-mortem examinations, the serum of the blood should be 
collected and allowed to stand, in order to see if it were milky or 
not. The state of the mesenteric glands, lacteals, and receptaculum 
chyli, should be particularly examined, and it would be desirable to 
inject the thoracic duct, first with transparent fluid injection, and 
afterwards distend it with a little strong size, when the course of 
the absorbent trunks might be traced, and, if necessary, parts sub- 
jected to microscopical examination. 



282 CHOLESTERINE 

Of Cholestebine in Urine. 

337. Composition of Fatty Katter passed in Cases of Fatty 
Defeneration of the Kidney.— Some years ago (1850), when examin- 
ing the iatty matter which accumulates in the epithelial cells passed 
in the urine in great number in some cases of fatty degeneration of 
the kidney, I was surprised to find that it contained a considerable 
quantity of cholesterine. The only cases in which cholesterine 
seems to have been detected in urine, are those which are referred to 
in Simon's ^^ Animal Chemistry,^' Gmelin is said to have found choles- 
terine in the urine in a case in which the flow of bile was impeded; 
and Moller twice detected it in kiestein, the film which rises to the 
surface of the urine of pregnant women, and contains sometimes 
much fatty matter. (Casper's " Wochensckr., Jan. 11 — 18, 1845; 
quoted in Franz Simon's ^'Animal Chemistry, ^^ Vol. II., pp. 313, 
333.) It is not stated, however, in these cases, if the crystalline 
form of the crystals was made out ; nor is it certain that the matter 
referred to was cholesterine at all. 

Other authorities, among whom is Lehmann, state that choles- 
terine has never been detected in urine. 

The first case which I examined was that of John Eyan, a patient 
in King's College Hospital in 1850, under the care of Dr. Todd. 
The urine was pale, of acid reaction; specific gravity 1020, and 
contained albumen. The pale flocculent deposit consisted princi- 
pally of fat cells. 

The deposit from upwards of seven gallons of urine was collected 
upon a filter. It was dried over a water-bath, and digested in a 
mixture of alcohol and ether. The solution was filtered, and after 
being concentrated by evaporation, was allowed to cool. Crystals of 
cholesterine were found in considerable number. These were sub- 
jected to microscopical examination. The fatty matter in this case 
was composed of at least three distinct forms of fat ; but, in conse- 
quence of the very small quantity obtained for observation, it was 
not possible to investigate their characters very minutely. The 
deposit from this urine contained — 

1. A dark brown fat in very small quantity, which was soluble 
in ether, but insoluble in hot and cold alcohol. 

2. A light brown saponifable fat, soluble in hot but insoluble in 
cold alcohol. 



IN THE URINE. 283 

3. A considerable quantity of pure cTiolesterine, which originally 
existed in the urine dissolved in the other fets. 

The next case of fatty degeneration of the kidney submitted to 
examination was that of a man named Tiedeman, also a patient of 
Dr. Todd's, in King's College Hospital. The case is published in Dr. 
Todd's " Clinical Lectures " (Case 107). See also " Archives of 
Mediciney^ vol. I. page 8. The fatty matter obtained from twenty-four 
pints of urine weighed only '47 grains, but from this a great number 
of crystals of cholesterine were obtained by extraction with alcohol. 

The deposit of the urine of a third case of fatty degeneration of 
the kidney has been submitted to examination, and cholesterine has 
been discovered in this instance also. 

In another case in which the deposit had been kept for some time 
in a preservative fluid consisting of wood-naptha, creasote, and water, 
the cholesterine had separated spontaneously from the other con- 
stituents of the oil-globules, in the form of rhomboidal tablets. 

The fatty matter deposited in the kidney in these cases also 
contains a large proportion of cholesterine ; and I have detected the 
presence of cholesterine in the fatty matter of so many organs in a 
state of fatty degeneration, as to justify the conclusion that the 
formation of this substance is intimately connected with the changes 
taking place in this morbid process. 

When cholesterine occurs in the urine, it is always dissolved in 
other fatty matters, so that its presence cannot be detected except 
by extraction with alcohol and subsequent crystallisation. It is one 
of the constant constituents of the minute fat-globules produced in 
the epithelial cells and casts of the uriniferous tubes, which are so 
characteristic of this form of kidney-disease. 

Surprise has often been excited by observing that oil-globules 
passed in the urine in these cases, sink to the bottom of the vessel, 
when we should expect rather to find the fatty matter rising to the 
surface by reason of its lightness. That the cell-walls and casts are 
not the sole cause of this subsidence, is proved by the fact that 
individual globules, quite free from these structures, are frequently 
found at the bottom of the vessel with the deposit. This subsidence 
is probably in some measure due to the quantity of the cholesterine 
entering into the composition of the fatty matter. Crystals of 
cholesterine sink in fluids of a specific gravity even some degrees 
above 1000. 



284 SUPPOSED PRESENCE OF 

838. Oholesterine said to be obtained from the TTrine in 
other diBeases.— I have not been able to detect cholesterine in the 
urine in any other morbid condition than in that above referred to. 
Although I have at present only searched for it in four cases of fatty 
degeneration, in consequence of the difficulty of obtaining sufficient 
quantity of the deposit to work upon, the circumstances which I 
have enumerated render it very probable that it is a constituent 
of the fatty matter present not only in the urine in all cases of 
fatty degeneration of the kidney, but that it is a constant con- 
stituent of the fatty matter present in all cells and tissues in a 
state of fatty degeneration. 

It has been stated by some observers, that cholesterine was to be 
obtained from the urine in several different forms of disease. Dr. 
Salisbury {^^ American Journal of the Medical Sciences,''* April, 
1863,) states that he detected cholesterine in eighteen specimens of 
morbid urine, but he does not appear to have tested the crystals he 
obtained, which in their general form certainly resembled choles- 
terine. This observer asserts that in diabetic urine be obtained a 
very large quantity of cholesterine. From a specimen of diabetic 
urine, which I examined by the process recommended by Dr. Salis- 
bury, I certainly obtained crystals very much resembling plates of 
cholesterine, but they were soluble in boiling ivater, and were found 
to consist of hippuric acid. Dr. Salisbury has not stated if the 
crystals he obtained were insoluble in boiling water, nor has he 
shown that they consisted of cholesterine. It has not yet been 
proved that cholesterine is ever excreted in a state of solution in 
the aqueous constituents of the urine, and it is very improbable that 
such a body should be so excreted. {See a paper of mine in the 
'^ British Medical Journal,'' 1863.) 

I have shown that cholesterine is a very constant constituent of 
the large cells (granular corpuscles) containing oil-globules, which 
are abundant in the fluid of ovarian dropsy, and sometimes in 
hydrocele, and in that found in cysts generally;* in similar cells, 
which are common in sputum, and are derived from the surface of 

* The bodies described as granular eorpusctest inflammation globules^ compound 
granular cells^ eaudation corpuscles, and known by other names, are really composed of 
a number of minute oil-globules, aggregated together in the form of a spherical mass 
which not unfrequently becomes invested with albuminous matter, resembling a cell- 
wall ; but I believe that usually the albuminous material is deposited with the oil- 
globules, and therefore that no true envelope or cell-waU exists. 



CHOLESTERINE IN URINE. 285 

the mucous membrane of the bronchial tubes; in the ceUs which are 
frequently very numerous about the small arteries of the brain in 
cases of white softening, in those found in cases of the so-called /a«y 
degeneration of the placenta, and in other situations. 

Cholesterine is not specially /orm^d in the liver, nor can it be 
regarded as a special excretion separated from the blood by the 
liver. It is a substance of, perhaps, much less importance physio- 
logically and pathologically than Dr. Flint and Dr. Salisbury are 
disposed to think. Nor is there reason to believe that the choles- 
terine found in the nerves is constantly being removed. It exists 
in largest proportion in the fatty matters of which the white sub- 
stance of the nerve-fibres is composed, and there is no reason for 
believing that this white substance undergoes active change. It is 
true cholesterine aud the allied lipoid, or non-saponifiable fatty 
matter, serolin, are found in the blood, but only mere traces are 
present. It is probable that these substances result from the disin- 
tegration of some of the tissues, but there is no reason for assuming 
that either of them perform any very important office, or that certain 
important symptoms sometimes present are due alone to excess of 
cholesterine in the blood. I cannot admit that Dr. Flint has made 
out " a new excretory function of the liver," consisting of the removal 
of cholesterine from the blood, or that he is justified in introducing 
the term " cholesteremia" as applicable to a newly-discovered disease. 
Every one knows that cholesterine is one of the constant constituents 
of bile ; but, to assert that the symptoms occurring in fatal jaundice 
depend upon the poisonous effects of an insoluble substance like 
cholesterine accumulating in the blood, is not justified by the facts. 
The symptoms have been explained much more satisfactorily already, 
without resorting to such an hypothesis. {See Dr. Flint's Paper — 
" American Journal of the Medical Sdences^^ October, 1862.) 

839. Kiestein.— Of this peculiar substance I can give no very 
satisfactory account. Some years since numerous observations were 
made by Nauche, and repeated by Dr. Golding Bird and several other 
observers, with the view of ascertaining if there was any foundation 
for the statement that, in pregnant women, certain elements of the 
milk found their way into the urine, and, after the lapse of a short 
time (twenty-four hours to five or six days), a thin pellicle, consisting 
of fatty matter, a substance allied to casein, and crystals of triple 



286 KIESTEIN. 

phosphate, formed upon the surface. Some went so far as to say that 
the presence of this pellicle was sufficient to indicate the existence 
of the pregnant state. This statement has, however, long since been 
proved to have no foundation in actual observation. In some of the 
cases brought forward by Dr. Golding Bird, the pellicle was absent ; 
in others, the pellicle was observed; and the conclusion he arrived 
at was, that, in cases in which the pellicle was formed, it was due to 
the presence of certain constituents of the milk, which, from not 
escaping from the gland in the usual way, had been reabsorbed and 
separated from the blood by the kidneys. 

I have not unfrequently seen a pellicle composed of animal 
matter, in which vibriones and fungi were abundant, and crystals of 
triple phosphate formed upon the surface of various specimens of 
urine which had been left to stand for a day or two, both from the 
male and from the female. Whether this is exactly the same sort of 
pellicle as that said to form upon the urine of pregnant women, I 
cannot say; but it possessed the characters usually assigned to the 
so-called kiestein. The animal matter has not been satisfactorily 
isolated, and is in many cases undergoing decomposition. In the 
absence of more exact information, we can attach no importance 
whatever to the presence or absence of this pellicle in the diagnosis 
of pregnancy. It may be absent in the pregnant state ; and it may 
be present in the male, and in the unimpregnated, as well as in the 
impregnated female. 

Otheb Fobms in which Fatty Matter occurs in Urine. 

840. XTrostealitli.— Dr. F. Heller reports a very remarkable 
case, in which small concretions, composed of fatty matter, were 
passed in the urine. The patient was a man, twenty-four years old, 
who suffered from symptoms of stone in the bladder. He passed 
several small solid bodies, which were found by Dr. Heller to consist 
of a peculiar form of fatty substance, to which he gave the name of 
urostealith. The man, who was treated with carbonate of potash, 
got quite well in a fortnight (quoted in Dr. Golding Bird's work, 
edited by Dr. Birkett, p. 422; Heller's " Archiv,'' 1844, s. 97, 1845, 
s. 1). Dr. Moore of Dublin has confirmed Heller's observations on 
urostealith. He examined specimens of this curious substance, which 
he received from Dr. Robert Adams of Dublin, and Dr. Little of Sligo 



FAT IN URINE. 287 

(" Dublin Quarterly Journal of Medical Sdence^^ May, 1854, Vol. 
XVII., p. 473). I have liad two or three specimens of solid fatty 
matter sent me, which were stated to have been passed in the urine, 
but the evidence was not conclusive. It was not certain, in one case, 
if they passed along the urethra at all ; and, in others, it was not 
proved that they were not passed up in the first instance. 

341. Fluid YeUow Fat and Oil aiobxQes.— Dr. C. Metten- 
heimer gives two cases in which large quantities of fluid yellow 
fat were passed in the urine. The first was a man sufiering from ' 
cancer of the lungs, who was taking a tablespoonful of cod-liver oil 
twice-a-day. The second was that of a woman who was recovering 
from acute inflammation of the kidneys, and was taking a mixture 
composed of henbane and hemp. {^^Archiv, des Vereins^^ B. I, Heft. 3.) 

Dr. Henderson, of Clifton {'^ Brit. Med, Joum,^' May 22nd^ 
1868), reports three cases, in which fatty matter in the form of fine 
oil-globules was suspended through the urine. The patients suffered 
from heart affection. The oil-globules were only seen on one or two 
occasions. The nature of the fatty matter could not be ascertained. 
From six drachms of the urine, of one case. Dr. Herapath obtained 
•016 grains of an oily fatty matter. Dr. Herapath refers to a case in 
which "a large dose of castor-oil was gradually, almost wholly, 
eliminated by the kidneys, during several days after administration." 
Dr. Henderson believed that the bottles in which the urine he 
examined, was collected, were perfectly clean, and he considers that 
perhaps the fatty matter was derived from the chyle, although no 
albumen was detected, which, however, would have been the case, if 
this supposition were correct. Dr. Henderson kindly sent me a 
little of the ethereal solution of the fat obtained from one of his 
cases ; but the amount was too small for chemical examination. 

342. Fatty Matter in Babbits' Urine.— Dr. Siegmund found 
a quantity of fatty matter in the urine of rabbits to which cubebs 
had been given. The excretion of fatty matter continued as long as 
the cubebs were administered. After death, no morbid change was 
discovered. It disappeared when the cubebs were omitted, but 
reappeared when they were administered again. The same observer 
also found that, although cantharides and cubebs irritated the 
kidney, they did not diminish the proportion of urea excreted. 



288 FAT IN URINE. 

848. Erroneous ObeervationB connected with the Freaenoe 
of Fatty Matter in Urine. — Numerous other instances, in which 
fat has been said to have been passed in considerable quantity, are 
on record; but there can be little doubt that, in many of these cases, 
the chemical characters of the substance supposed to be &tty were 
not carefully ascertained. There is reason to believe that the 
iridescent pellicle, which really consists principally of fungi, yibriones, 
and crystals of triple phosphate, from its general resemblance to a 
thin film of oily matter, has been mistaken for fat. Small portions of 
oily matter not uncommonly become mixed with the urine acciden- 
tally, and now and then the urine is put into an oily bottle and sent 
for examination. Even a single drop of oil, shaken up with three or 
four ounces of urine, becomes divided into a great number of minute 
oil-globules, and upon microscopical examination there appears to be 
a much larger quantity of fatty matter present than is really the 
case. Many practitioners have been deceived in consequence of the 
admixture of milk with urine. This is not an uncommon practice, 
and we should be very careful not to be misled by impositions of 
this kind. It is hardly credible what trouble some patients will take 
to deceive us; and very often deception is practised and carried on 
for a long time without detection. From not being able to discover 
any reasonable motive, we are sometimes too ready to conclude that 
our suspicions are unfounded ; and thus we may be led to believe 
statements which are really false, and report cases apparently of a 
very exceptional character, which only prove that great ingenuity 
has been employed for the mere purpose of imposing upon us.* 

* I am mnch interested in the question of the removal of fatty matter by the 
kidneys; and I shall be very much obliged to any one who will send me specimens of 
nrine containing f&tty matters in any unusual form, or reports of well authenticated 
cases. 



289 



CHAPTER XIY. 



Urine in Disease. II. Of Light and Flocculent Deposito. 
Mucus — Altered Pus resembling Mucus — Of the Clinical 
Importance of Mucus — Incontinence of Urine not dependent 
upon Organic Disease — On the Treatment of Irritable Blad" 
der and Incontinence of Urine — Vibriones — TortdcBy including 
the Sugar Fungus and Penicillium Glaucum — Sardnce-^ 
Trichomona's Vagime — Epithelium of Kidney^ Ureter^ Blad' 
der, and Urethra — Vaginal Epithelium — Casts of the Ute^ 
rus and Vagina — Leticorrhcea — Of the Treatment of LeU" 
corrhcea — Spermatozoa — Medico-legal Investigation — Vege^ 
table Bodies resembling Spermatozoa — Casts of the Renal 
Tubes — A. Ca^ts of Medium Diameter y about the (me-seven" 
hundredth of an inch — Epithelial Casts — Casts containing 
Dumb Bells — Granular Epithelial Casts — Ca^ts containing 
Oil — Fat' Cells — Casts containing Blood — Casts containing 
Pus, B. Casts of Considerable Diameter^ about the one-fivC' 
hundredth of an inch — Large Waxy Casts. C. Ca^ts of 
Small Diameter^ about the one thousandth of an inch — Small 
Waxy Casts — Of Casts in a Clinical point of view. 

Op Urinary Deposits. 

It will be convenient, for the purposes of description, to arrange 
these insoluble substances in a certain order; and I think that the 
subdiyision I have adopted will be found of some assistance to the 
memory, and will help the observer to discover quickly the nature of 
different insoluble substances. I do not make an attempt to devise 
a natural classification, but merely propose to arrange deposits in the 





290 CLASSIFICATION OF DEPOSITS. 

order in which they can be practically treated of most conveniently. 
There are objections to this, as to every other sub-division ; but, as 
it is simple, and depends merely upon the general characters which 
can be observed by the unaided eye, I think it will be found 
practically useful. 

Insoluble substances m^j float on the surface of the urine, or may 
be diffused throughout the fluid, or they may sink to the bottom, 
forming deposits of greater or less density. 

1. Insoluble Matter floating upon the Surface of Urine, or 
diffused through the Fluid. Fatty matter in a very minute state of 
division, as it occurs in cases of chylous urine, is one of the most 
important substances contained under this head, and has been already 
considered. 

Urate of Soda is another substance which is often suspended in 
a molecular state through the fluid, rendering it turbid; but this 
also forms a deposit, and it will therefore be more convenient to 
consider it under that head. Phosphates are found not unfrequently 
in the pellicle upon the surface of urine ; but in this case they are 
merely buoyed up, as it were This substance will be described 
under urinary deposits. 

2. Light and flocculent Deposits, usually transparent, and 
occupying considerable volume. Under this head I shall include 
mucus, with different forms of epithelium derived from the kidney, 
ureter, bladder, urethra, vagina, &c., ; certain well-defined forms of 
fungi and vibriones ; sarcinae ; spermatozoa ; casts of the uriniferous 
tubes ; rarely, benzoic acid in small quantity {See note on page 165). 

3. Dense and opaque Deposits, occupying considerable bulk. 
This class includes only deposits of urates, pus, and phosphates. 

4. Granular or crystalline Deposits, occupying a small bulk, 
sinking to the bottom, or deposited upon the sides of the vessel. 
This division includes a great many different substances. Among 
the most important are uric acid, oxalate of lime, certain forms of 
triple phosphate and phosphate of lime, cystine, carbonate of lime, 
blood-corpuscles, and very rarely, cancer-cells, tubercle-corpuscles, 
and small spherical cells. 

I proceed now to the consideration of the different substances 
comprised in the first class of urinary deposits. Many of these 
occupy a considerable bulk, although the actual quantity of matter 
entering into the formation of the deposit is exceedingly small. If 



MUCUS, ALTERED PUS. 291 

dried, one of the most bulky of these deposits, separated from six or 
eight ounces of urine, would hardly weigh half a grain. The mode 
of separating urinary deposits from the urine, of examining and 
preserving them, is described in Chapter III., § 62, et seq. 

II. — First Class op Urinary Deposits. 

844. Iffucus. — If healthy urine be allowed to stand for a few 
hours after it has been passed, a bulky, flocculent, and very trans- 
parent cloud will be deposited towards the lower part of the vessel* 
Upon examining this in the microscope, a few delicately granular 
cells, rather larger than a blood-corpuscle may be seen, scattered 
sparingly through a transparent substance, in which only a few 
minute granular points can be detected. A few cells of epithelium 
from the bladder, or from some other part of the urinary mucous 
membrane, are not unfrequently met with. Nothing more is 
observed in the mucus found in healthy urine. In disease, however, 
this mucus increases in quantity, and forms a more or less trans- 
parent deposit, containing numerous ill defined cells, similar to those 
above referred too, with much epithelium, the character of which 
depends upon the particular part of the mucous membrane from 
which it has been derived (§§ 353, 354). The characters of ordinary 
vesical mucus are represented in Fig. 85, Plate XVII. The larger 
cell to the left of the figure is a cell of bladder epithelium. 

Little collections of mucus, with imperfectly formed cells, are not 
unfrequently seen in urine. These are generally derived from the 
follicles of the urethra, or from the prostate. Long shreds of mucus- 
like material are sometimes formed in the kidneys and in the seminal 
tubules, and escape with the urine. (Plate XVII., Figs. 83, 84; 
''lUustrations;' Plate XIII., Fig. 2.) 

846. Altered Pus, resemblinfir Mucus.— The very thick glairy 
deposit, which is frequently found in the urine in cases of disease of 
the bladder, is often termed *mwcw«,' but its real nature is very 
different. It consists, in fact, of pus altered by the action of car- 
bonate of ammonia which has been set free in consequence of the 
decomposition of the urea caused by some animal matter acting as a 
ferment after the urine has left the bladder. In some cases, this 
change even commences in the bladder itself; and the expulsion of 

3 



292 CLINICAL IMPOBTANCE 

the glairy viscid matter often gives rise to serious inconvenience. 
When an attempt is made to draw off the urine with a catheter, the 
instrument sometimes hecomes completely plugged up. Urine of 
this kind exhibits a highly alkaline reaction, evolves an ammonlacal 
odour, and frequently contains a considerable deposit of crystals of 
the triple or ammoniaco-magnesian phosphate, with granules of 
phosphate of lime. Liquor ammonisB and potash exert an action 
upon pus similar to that of carbonate of ammonia. 

I have observed, in several cases, that when pus comes from an 
abscess in the kidney, or from the pelvis of the kidney, it is not 
accompanied with crystals of triple phosphate. On the other hand, 
when it is derived from the bladder, crystals of these earthy salts are 
almost invariably present. This point should be taken into con- 
sideration before arriving at a diagnosis in doubtful cases. 

It should be borne in mind that, if basic phosphate of soda be 
added to urine, ammonia is always set free in considerable quantity. 
Dr. G. 0. Rees suggests that the ammonia is often set free in this 
manner, and not by the decomposition of the urea. The same 
observer (Lettsomian Lectures, ^^ Medical Gazette" 1851) considers 
that the alkalinity of the urine is dependent in certain cases upon 
the secretion of a large quantity of an alkaline fluid from the mucus 
membrane of the bladder. When the mucus membrane is exposed, 
it is always found to be moistened by an alkaline fluid. When 
irritated, a quantity of this alkaline fluid, supposed to be more than 
sufficient to neutralise the acidity of the urine, is poured out. 
Dr. Rees explains the fact, that the acid reaction of urine not un- 
frequently becomes more intense after giving alkalies, by supposing 
that the alkali allays the irritable state of the mucous membrane, 
which, in consequence, secretes less of the alkaline fluid. In injuries 
to the spine, the beneficial action of alkalies is explained by sup- 
posing that the mucous membrane requires a greater quantity of 
alkali to protect it than in health. Still it is difficult to associate 
this explanation with the fact that healthy urine is always acid. 
If a slight increase of this natural acid really endangered the in- 
tegrity of the mucous membrane, by exciting the secretion of excess 
of a destructive alkaline substance, one is almost forced to the false 
conclusion that the actual condition which exists is not so advan- 
tageous to the individual as the existence of a mucous membrane 
adapted to bear without change the constant action of an acid fluid 



OF MUCUS. 293 

would be. Moreover, in a vast number of cases, urine, containing a 
very considerable excess of acid, does not produce the result just 
alluded to. 

The mucus which is deposited from many specimens of urine 
often contains a great number of octohedral crystals of oxalate of 
lime, frequently so very minute as to appear, under a power of two 
hundred diameters, like a number of dark but square-shaped spots. 
Their crystalline form may be demonstrated by the use of a very high 
power; but they may be recognised with certainty with a little 
practice, as their square shape presents a characteristic appearance, 
with which the eye soon becomes familiar. They are insoluble in a 
solution of potash, and also in strong acetic acid. These crystals are 
commonly not deposited until after the urine has left the bladder; 
and if it be allowed to stand for a longer period, they frequently 
undergo a great increase in size. It is probable that the mucus 
excites change in the urates, causing their decomposition, and the 
formation of oxalate of lime. Fragments of hair, small portions of 
cotton fibre, and other substances of accidental presence, are not 
unfrequently encrusted with them. 

346. Of the Olinical Importanoe of KCuons. — Although, as 
already stated, the great majority of cases in which the urine is 
said to contain large quantities of mucus, are really examples of pus 
in the urine, which has been rendered glairy and transparent by the 
action of ammonia, true mucus is sometimes found in the form of 
long transparent shreds, which are scarcely visible unless the field 
of the microscope be illuminated very slightly. Rich transparent 
mucus shreds may be derived from several parts of the urinaiy 
surface ; they may come from the follicles of the urethra or prostate, 
from the vesiculae seminales, from the vas deferens, or from the 
seminal tubules. I have seen the most distinct branching cylin- 
drical masses of mucus from the uriniferom tubes in many instances 
{see Plate XVII., Figs. 83, 84). These cases do not appear to have 
been noticed previously. The character of these " mucus casts *' is 
discussed in page 61. Their formation is sometimes associated with 
an irritable state of the urinary organs generally, and, in very many 
cases of irritable bladder, evidently not depending upon organic 
disease, small quantities of mucus, in the form of cylinders, may be 
detected in the urine. 



294 INCONTINENCE OF URINE. 

This mncus is very soon destroyed by maceration in fluid, and, 
unless the urine be examined very soon after it has been passed, 
the distinctive character of such mucus-casts will have disappeared. 
If urates be present in the urine they will be deposited in and upon 
the mucus, in which case the mucus-casts form very prominent 
objects. Minute crystals of oxalate of lime are also frequently de- 
posited upon these casts. There is no difficulty in distinguishing 
these bodies from the true casts, wrongly termed "fibrinous;" for, 
although composed of a firm elastic material, casts do not consist of 
fibrin {zee § 105). 

847. Inoontinence of Urine not dependent upon Organic 
Disease.— In irritable conditions of the bladder and urinary organs 
generally, there is sometimes an increased secretion of mucus, but 
this is not constantly the case; and all practitioners are familiar 
with cases of incontinence of urine, not dependent upon any organic 
disease whatever, in which the urine does not contain the slightest 
deposit of any kind. Some of these cases are very obstinate. The 
condition is frequently met with, but perhaps more commonly, in 
young and old people than in persons about the middle periods of life. 

As is well known, incontinence of urine is very common in young 
children, and may depend upon almost any peripheral irritation, 
such as dentition, intestinal worms, enlarged glands, &c., but very 
often it is connected with a naturally excitable state of nervous 
system. Commonly enough, it occurs only during the night, and 
sometimes the child acquires a liahit of thus voiding the urine, unless 
care is taken by the nurse to take him up regularly after certain 
intervals of time (three or four hours), so as to prevent much urine 
from accumulating in the bladder. In many cases the urine is a 
little too acid, when a few doses of bicarbonate of potash and 
attention to diet will relieve the troublesome affection. 

In old age the bladder often becomes very irritable, although 
there is no morbid change whatever in its structure, and a patient is 
unable to retain his water for more than half-an-hour or an hour at 
a time. Any disturbance of the digestive organs will sometimes 
produce increased distress. The urine is perhaps too acid or too 
highly concentrated. Patients who suffer thus, by concentrating 
their attention too much upon their ailment, often make matters 
worse. 



IRBITABLE BLADDER. 295 

Incontinence of urine may, of course, be produced by a great 
variety of conditions. Its occurrence in inflammation of the bladder,- 
cancer, and some other conditions, will be referred to in the proper 
place. 

848. On the Treatment of Irritable Bladder and Inoon- 
tinenoe of Urine, not depmident upon Orgranic Disease. — This 
affection will require different treatment according to the age at 
which it occurs. The irritable bladder of children generally depends 
upon peripheral nervous irritation, and is often relieved by gentle 
purgatives, and small doses of alkalies. When arising from teething 
or from worms, the treatment is obvious. In young children, 
incontinence occurring during the night need cause no alarm 
whatever, as it generally passes off as the child grows older. 

This troublesome symptom occurs in young persons of both 
sexes, and is occasionally very obstinate. Not unfrequently it seems 
to be due to the habit of sleeping on the back, when a blister 
applied to the buttocks will generally cure the malady by com- 
pelling change of position. I have seen it in youths of scrofiilous 
habit whose strength has suffered from growing too fast. Such cases 
are almost certainly cured by a generous diet, the tincture of sesqui- 
chloride of iron, quinine, and cod liver oil, but it is often necessary 
to keep the patient under this plan of treatment for two or three 
months. 

Nervous old men often suffer a good deal of inconvenience from 
irritable bladder not dependent upon organic disease. If they 
take a little more wine than they ought, or live on a richer di^t 
than usual, or become a little more irritable in temper, they 
will be called up several times in the night. The state of urine 
causing this annoyance is generally dependent upon the stomach 
being a little out of order, and a few doses of bicarbonate of potash 
after meals, a mild sedative and a gentle purge, generally relieves 
the annoyance. Sometimes a small dose of blue pill or calomel 
affords great relief. If obstinate, it m well to try the effect of an 
opium or henbane suppository. 

849. Vibriones.— After urine, containing a little epithelium or 
other animal matter, has been allowed to stand for some time, 
numerous elongated bodies, varying much in length and possessing 



296 TORUUE — ^yiBRIONES. 

actiTe moTements, are developed in it These little bodies appear 
as simple lines under a magnifying power of two hundred diameters; 
but, by careful focussing, under one of five hundred or six hundred 
diameters, the longest of them are seen to consist of filaments with 
numerous transverse lines, indicating a similarity of structure with 
some of the lower vegetables. They sometimes very closely resemble 
the algae ordinarily found in the mouth. Most observers agree as 
to the vegetable nature of the bodies in question ; but Dr. Hassall 
has recently arrived at the conclusion that they are animal, and that 
the movements are voluntary (" Lancet^^ Nov. 19th, 1859). That 
the movements are not merely molecular, is quite certain ; but, to 
apply the term " voluntary" to such movements as these, seems to 
me quite unjustifiable. There is not the slightest evidence in fevonr 
of such a conclusion. As investigation proceeds, the conclusion that 
many forms, which were considered animal, are really of a vegetable 
nature, is more frequently forced upon us than that organisms, 
hitherto held to be vegetable, must really be regarded as animal. 
The time has, however, gone by, when attempts were made to draw 
an arbitrary line between the lowest classes of the animal and 
vegetable kingdom. 

These vegetable organisms are seen as minute lines under the 
microscope, and they undergo very active movements, the longer 
ones twisting about in a serpentine manner. They are sometimes 
developed in urine before it has left the bladder, and always occur 
in decomposing urine. {See Plate XV., Fig. 73 at 6.) 

Other living organisms are frequently met with in urine. Nu- 
merous forms of animalcules, one of which Dr. Hassall includes in 
the genus hodo {bodo urinarius), are also observed in various spe- 
cimens. It is probable that many of these different forms merely 
indicate different stages of existence of one species. 

860. TorolsB, indiidiiifir the Su^ar-Fniigiis and Penicilinzn 
aiaucom.— Certain forms of vegetable fungi or torulae are developed 
in urine after it has been standing for some time. The period which 
elapses before the appearance of the fungi, and the particular species 
which is developed, vary much in different specimens of urine, and 
in different cases of disease. In diabetes, torulaB are sometimes deve- 
loped in considerable number within twenty-four hours after the 
urine has been passed ; and their growth at this early period leads 



PENICILIUM GLAUCUM. 297 

the observer to suspect the presence of sugar, which must be con- 
firmed by the application of chemical tests (§§ 276, 277). Different 
forms of fungi are represented in Plate XV., Figs. 73, 74, 75. {See 
also "Illustrations;' Plate XIX, Figs. 1 to 7; Plate XXL, Fig. 6; 
Plate XXIII., Figs. 2, 3, 4, 5.) 

Sugar Fungus, Dr. Hassall has communicated a paper upon 
the development of torulae in the urine, to the RoyaJ Medical 
and Chirurgical Society, which will be found in the volume of 
" Transactions *' for 1853, in which he arrives at the conclusion 
that there is a species of fungus which is developed in specimens of 
urine, containing even very minute traces of sugar, which may be 
looked upon as characteristic of the presence of this substance, as it 
occurs in no other condition of the urine. This is the sugar fungus. 
But neither the characters nor the occurrence of the fungus are 
suflSciently constant to enable us to conclude positively as to the 
presence or absence of sugar in the urine. The sugar fungus which 
grows in diabetic urine is identical with the yeast plant. {See Fig. 
66* Plate XIIL, after Hassall.) 

Penidlium Glauoum, Besides the sugar fungus, there is another 
species which is very commonly met with in acid urine containing 
albumen, if exposed to the air. This is the Penidlium glaucum, the 
same fungus which is developed in the lactic acid fermentation 
(Plate XV., Figs. 73, 74, 75 ?). This species is also represented in 
the *' Illustrations;' Plate XIX., Figs. 1, 4, 5. 

The microscopical characters of the fungi in different specimens 
of urine vary considerably; but these differences depend not so much 
upon the existence of several distinct species of plants, as upon 
the stage of development which the fungus has reached. Thus, as 
Dr. Hassall has stated, in some specimens, the growth of the fungus 
is arrested at the sporule stage; in another, not until a thallus is 
formed; and in a third, it goes on until aerial fructification takes 
place, and new spores are developed. But it is only in the last 
condition that constant distinctive characters can be demonstrated. 
The degree of acidity of the urine, and the length of time during 
which it has been exposed to the air, appear to determine, in great 
measure, the stage of development which the fungus attains. 
Dutrochet long ago stated that an acid reaction and albumen are 
necessary for the development of penicilium; but Dr. Hassall, in 
some more extended experiments, proved that the fungus often 

5 



298 SABCINJS. 

appeared in add urine which contained no albumen; and I have 
frequently observed the same point myself. 

The penicilium glaucum, as well as the sugar fungus, may be met 
with in saccharine urine, because all the necessary conditions for its 
development may be present, namely, exposure to air, an acid liquid, 
and a certain quantity of nitrogenous matter. Mr. Hoffman, of Mar- 
gate, showed that the spores of penicilium would, under favourable 
circumstances, give rise to the development of the sugar fungus. 

As Dr. Hassall was, I believe, the first to prove, the fructification 
of these two fungi is totally distinct, and in this stage of growth, no 
one could fail to distinguish one from the other. But I am sure no 
microscopist could distinguish these fungi during the sportUe stage, 
and although the thallus of well developed penicilium differs from 
that of well developed sugar fungus, I have seen thalli of these fungi 
which resemble each other in thickness, mode of branching, and in 
very minute characters. So that, although in their perfect condition 
the two fungi exhibit distinctive characters, it is only in this stage 
that we can demonstrate them to be distinct species. 

Dr. Hassall, in his recent work on the urine, represents the 
sporules of the sugar fungus as being very much larger than those of 
penicilium glaucum. I have seen many specimens in which the 
sporules were the same size, and it is easy to obtain sporules of the 
sugar fungus much smaller than those of penicilium. 

From a careful consideration of this question, then, I think we 
may conclude that although well defined differences may be made 
out in the perfect state of development of these fungi, Penicilium 
glaucum and Torula cerevisice, it must be conceded that there are 
also forms at certain stages of growth which could not be distin- 
guished from one another. The large circular sporules of the sugar 
fungus are distinct enough from those of penicilium glaucum ; but 
oval and circular sporules, which cannot easily be distinguished, are 
to be obtained under certain circumstances from each plant. 

851. SarcinaB are little vegetable organisms in the form of little 
cubes, which are from time to time met with, in the matter rejected, 
in peculiar cases of obstinate vomiting. They have been observed, 
however, in other fluids, and occasionally occur in the urine ; but 
the sarcinaB which I have seen in the urine were smaller than those 
which are usually observed in vomit. 



EPITHELIUM, KIDNET, BLADDER. 299 

SarcinsB have been met with in the urine by Heller, Dr. Mackay, 
Dr. Johnson, and by myself, under circumstances ^hich leave no 
doubt that this vegetable organism is sometimes developed in urine. 
I once analysed a specimen of urine containing sarcineB, which was 
sent me by my friend Dr. Brown, of Lichfield. It was acid; specific 
gravity, 1018-6. 

Analysis 65. 

Water 952*8 

Solid Matter 47*2 

Organic Matter 37*9 

Fixed Salts 9*3 

The specimen was carefully examined for lactic acid, but not a trace 
could be detected. SarcinsB in vomit are represented in Plate 
XXIL, Fig. 118. 

352. Trichomonas VaerinsB. — Donn6 some years ago described, 
under the name of Trichomonas vagina, an organism which he 
considered to be of an animal nature. It consists of a rounded cell, 
with vibratile filaments projecting from it, and was found in the 
urine of females suffering from leucorrhoea. KoUiker and Scanzoni 
have confirmed Donne's observations, and have detected the tricho- 
monas in the vaginal mucus both of impregnated and of unim- 
pregnated women. I have never been fortunate enough to meet with 
a specimen of this organism. 

353. Epithelium of Kidney, Bladder, and Urethra. — ^The 
epithelium from the kidney has been already described. It is 
figured in Plate IX., Fig. 44; and in the ^'Illustrations,'" Plate 
XXIV., Figs. 1, 2, 3, 4. The cells from the ureter are of the 
columnar form, and some are spindle-shaped. (Plate IX., Fig. 46; 
also ''Illustrations,^^ Plate XXIV., Fig. 5.) In form, and indeed 
in their general appearance, these cells much resemble those found 
in some scirrhus tumors. Care must be taken not to make the 
mistake in cases of suspected cancer of the kidney. 

The epithelium of the bladder varies much in different parts of 
the organ. In the fundus, there is much columnar epithelium 
mixed with large oval cells; whereas, in that part termed the 
trigone, large and slightly flattened cells, with a very distinct nucleus 
and nucleolus, are most abundant. Columnar epithelium appears to 



300 VAGINAL EPITHELIUM. 

line the mucous follicles, while the scaly lies on the surface of the 
mucous membrtne between them. Many of the large oval cells of 
bladder-epithelium lie upon the summit of columnar cells, and their 
under surface exhibits corresponding depressions. Various forms of 
bladder-epithelium are represented in Plate XV., Fig. 76; Plate 
XIX., Fig. 100; and in Plate XXII., Fig. 120; the manner in which 
the young cells of yesical epithelium multiply, is represented under 
a power of 700 diameters. The young cells are composed of a per- 
fectly soft granular material, and like other young cells possess no 
limitary membrane or cell-wall whatever. These large cells of 
bladder epithelium grow very fast in cases of epithelial cancer, 
affecting this organ. {See § 421.) 

The epithelial cells of the urethra are, for the most part, of the 
columnar form; but mixed with this there is also a good deal of scaly 
epithelium. Towards the orifice, the epithelium is almost entirely 
of the scaly variety. The epithelium of the glans is of the scaly 
variety, and mixed with it is a quantity of soft white matter, seen 
under the microscope to consist of granules and numerous globules 
of fat, rich in cholesterine, with granules and globules of earthy 
phosphate. This is the secretion from the modified sebaceous glands 
in the mucous membrane of the corona, the so-called Smegma Pre- 
putii, which accumulates in some cases to an enormous extent. In a 
specimen, which was removed by operation by my friend Mr. Bird, 
now of Melbourne, I found epithelial cells with many well formed 
crystals of cholesterine. Upon analysis, the following constituents 
were detected and estimated in ten grains. 

Analysis 66. 

Water 7*46 

Solid Matter 2*54 

Extractives soluble in alcohol and cholesterine '24 

Epithelium, &c 2*02 

Fixed Salts -28 

364. Vasrinal Epithelixun.— The large cells of scaly epithelium, 
so commonly met with in the urine of females, and derived from the 
vagina, are represented in Plate XV., Figs. 77, 78. They vary, how- 
ever, much in size and form, and are sometimes very irregular in 
shape, with uneven ragged edges. 



FUNGI- BLADDER AND VAGINAL EPITHEFJUM. 



PIJ^TE XV. 



Vig' 73. 



,*::i-5^;*;*3i- 






t 

§ § 327, 330 



Fi^. 74. 



Fig. 73. 



x2I5 
§ § 350, 351 




oa 



^ 



§ 350 




Fig, 76. 

r%. ^T m^ 















iJ 



Am ^ 

D ^ ^ ..IS 

§ 353 



rig. 77. 



"12. 7S. 






mm 








§ 354 



To.f«ce v>(\y*''?*^.^. 



r 



CASTS OF UTERUS AND VAGINA. 301 

366. Oasts of the Uterus and Vasrina. — A considerable thickness 
of the epithelial layer of the vagina^ and according to some observers 
also that of the uterus, is sometimes shed in the form of a mem- 
branous cast or mould. I have seen such epithelial casts or moulds 
from the rectum, aesophagus, and from the stomach. They correspond 
to the layers of cuticle which are detached from different parts of 
the cutaneous surface after scarlatina. 

Dr. Arthur Farre has recorded some interesting cases of "ex- 
foliation of the epithelial coat of the vagina," in Vol. I. of my 
^^ Archives'' The appearance of the specimens is represented in 
Plate XII. of the ^^ Archives of MedidneP Dr. Farre remarks that 
the act of exfoliation is repeated at intervals. The casts described 
by Dr. Farre are interesting in another point of view, as showing the 
real form of the vagina when in its ordinary empty and collapsed 
condition. {See ^^ Archives,'^ Vol. I., p. 71.) Dr. Tilt has also 
described some interesting cases of the same kind. His opinion is, 
that some of these casts come from the uterus, while others are formed, 
as Dr. Farre stated, in the vagina. The beautiful specimen figured 
in Plate XVI., Fig. 79, is one of those examined by Dr. Tilt and 
considered by him to come from the uterus, although the character 
of the epithelium of which it was composed, agree more closely with 
those of the vaginal cells. {See " Archives" Vol. III., p. 26.) 

366. Leucorrhoea.— In this condition very many imperfect cells 
of vaginal epithelium are formed upon the surface of the mucous 
membrane, as well as pus-corpuscles. Many pus-corpuscles originate 
in the cells of vaginal epithelium, even after the epithelial cells have 
assumed their distinctive form, but many of the younger cells of 
vaginal epithelium, and those in the follicles of the mucous 
membrane, divide and subdivide, giving rise at length to multitudes 
of the spherical granular cells we know as " pus-corpuscles," which 
divide and subdivide very rapidly if freely supplied with nutrient 
matter. For the manner in which pus is formed from the germinal 
matter of vaginal epithelium, see Plate XIX., Fig. 98; and for the mode 
of multiplication of the pus-corpuscles, Plate XIX., Figs. 97, 99. 

357. Of the Treatment of Leucorrhoea. — Although it is not 
the province of this work to discuss the nature and treatment of 
leucorrhoea, it may be well to state, that many cases seem to depend 



802 SPERMATOZOA. 

upon an impoverished state of blood, and get quite well, if atten- 
tion be paid to the general health. Of all remedies the tincture 
of sesquichloride of iron is one of the most useful, and when there is 
any irritability of the mucous membrane, tincture of henbane, opium, 
or hop, or the extract of indian hemp, will be found useful. The local 
application of Goulard water with sedatives, and the injection of cold 
or tepid water, and the beneficial effects of the cold or tepid hip- 
bath, in this condition, are so well known to practitioners, that it is 
almost needless to refer to them. 

868. Spermatozoa.— The urine should be examined for sperma- 
tozoa, soon after it has been passed, as they may undergo change. In 
some specimens of acid urine, in which vibriones are not developed, 
the spermatozoa may be preserved for days without destruction. 
They may be distinguished with a power of about two hundred 
diameters ; but, unless the eye is familiar with them, it is better to 
employ one of from four hundred to five hundred. In one case, I 
met with spermatozoa covered with granules of urate of soda, which 
rendered the forms very distinct. ' 

Spermatozoa often form, with the mucus from the seminal tu- 
bules, whitish flocculi, which are suspended in the urine. They 
may, however, sink to the bottom, forming a deposit invisible to the 
unaided eye. Spermatozoa are represented in Plate XVI., Figs. 
80,81. 

869. Mucus Oasts from the Seminal Tubules are sometimes 
found in the urine. Some are very roughly represented in Plate 
XIII., Fig. 2, of the " Illustrations,^* Occasionally spermatozoa are 
packed together in great number, so as to form, with the mucus in 
which they are embedded, casts of considerable dimensions. A very 
good specimen is represented in Plate XVI., Fig. 80, from the urine 
of an old man of 80. 

860. Of the Olinical Importance of Spermatozoa in Urine. — 
Spermatozoa are not uncommonly found in the urine in health. It 
is only when their appearance is constant, and accompanied with 
other more important symptoms, that the practitioner is justified in 
interfering. I would earnestly draw attention to the importance of 
exercising the greatest caution in these cases ; for the mere allusion 
to the presence of spermatozoa may do more harm to a nervous 



CAST OF VAGINA-SPERMATOZOA. Plate XVJ. 

Fig. 79. 







§ 353 



Fig. 81. 






1 



X- 



\ 



§ 358 




x4oa 

To face paye^^'i. 



CLINICAL IMPORTANCE. 303 

patient than can be counterbalanced by the good produced by medi- 
cal treatment. The occasional presence of spermatozoa in urine must 
not be looked upon, in itself, as evidence of that condition to which 
the name of "spermatorrJuxa'^ has been applied — a term which I am 
sorry to employ at all, and which, I think, ought to be abolished 
altogether. There is, in fact, no disease to which the term " sperma- 
torrhoea" can be correctly applied. Spermatozoa are commonly found 
in the urine. The secretion of the testicle, like that of other glands, 
must, from time to time, escape. Spermatozoa are frequently seen in 
the urine of young men in perfect health, and I have seen considerable 
numbers in the urine of a hale old man above 80 years of age. This 
was a decided case of "spermatorrhoea;" and there is no doubt, that 
if this old gentleman's urine had been examined by some of the 
quacks who pretend to make this "disease" a special study, he would 
have been favoured with a list of the frightful consequences of this 
dire condition, and perhaps subjected to the appropriate remedies for 
preventing cerebral congestion, phthisis, epilepsy, general paralysis, 
insanity, and the other horrors which are stated by some persons to 
result from the involuntary escape of the secretion of the testicle.* 

* In a former edition of this Work, and also in "2%e Microscope in its Application to 
Practical Medicine" I have expressed in plain terms my own opinion upon the nse tit 
this detestable word, and I have foand no reason to sdter my view ; but as several 
pages of some works recently published are devoted to the consideration of "sper- 
matorrhoea and impotence," it is necessary for me to state more ftilly why I have 
expressed myself in a manner which, to some, may perhaps have appeared hasty and 
unsupported by evidence. 

One author has complained that some of our Hospital Physicians have &llen into 
the * error ' of making too light of this affection, and one or two in particular have 
even gone the length of ignoring its existence altogether. It is only right that I 
should admit that I fall under this 'stigma' (?), and it is but due to those who differ 
from me that I should give reasons for the opinion which, in common, I believe, with 
very many medical practitioners, I have long held upon this matter. The position I 
have te^en up is simply this— that there is no such disease as '* spermatorrhoea,'* as 
usually defined. 

It has been truly stated, that charlatans, for their own selfish purposes, too often work 
upon the fears of their patients, and exaggerate the evil consequences to be anticipated ; 
but wliat encouragement does the practitioner afford, who, under the head of con- 
sequences of spermatorrhcea, includes "phthisis, cerebral congestion^ epilepsy ^ general 
paralysis and insanity— lastly, enfeebled sexual power, anduUimaiely impotence*! (Hassall) 

These have been stated to be consequences of ''spermatorrhoea," but we are not 
informed whether 'possibie ' or * probable.' Spermatorrhoea has been defined to be *' all 
losses of seminal fluid not occurring as the result of sexual intercourse." As the 
heading " Spekmatobrh(ea and Impotence" has been adopted, we are clearly justified 
in concluding that impotence, to say the least, is regarded by some as not an uncommon 
consequence of "spermatorrhoea." I have seen many cases which have been called 
"spermatorrhoea," but I never saw^ne which ended in any of the above terrible 
consequences. That impotence does occur I do not deny, but lasting impotence, not 
depending upon some congenital defect, or some obvious structural morbid change, 
is a most uncommon affection ; indeed, I have myself never met with a single case. 

I have been unable to arrive at any other conclusion than this — that spermatOT' 
rhoea, as d^ned, is not a disease at aU, All practitioners are weU acquainted with the 
real nature of the cases included under this head. It seems to me neither necessary 



304 VEGETABLE BODIES 

861. ICedioo-Iiefiral Investifiration.— We are sometimes called 
upon to examine stains upon linen, or the vaginal mucus, in cases 
of suspected rape. Such an inyestigation must be undertaken with 
the greatest care, and a positive opinion must not be expressed if 
the observer have the slightest doubt as to the nature of the bodies 
in question ; neither should a positive conclusion be drawn from the 
presence of only one structure like a spermatozoon, nor from supposed 
fragments of their bodies. Fragments of cotton or linen sometimes 
assume forms very like those of spermatozoa. The mucus which has 
been dried on the linen, even after it has been kept for some time, 
in which they are suspected to be present, may be remoistened with 
distilled water, without the spermatozoa being destroyed. For cases 
in which spermatozoa were detected, see '^Archives of Mediciney'* 
Vol. I., pp. 48, 139; '' Illustrations," Plate XXI., Fig. 2. 

802. Vegretable Bodies resembling' Spermatozoa. — The only 
structure occurring in urine, or of renal origin, at all liable to be 
mistaken for spermatozoa, as far as I am aware, is a form of 
vegetable growth which I have only once met with, in a specimen 
of urine kindly sent to me by my friend Mr. Masters, of Peckham 

nor decent to allade to all that has been said upon the subject, or to recount the cmel 
and often useless and unnecessary means that have been proposed and adopted for the 
treatment of losses of seminal fluid. 

It cannot be too widely known that the importance attached to this so-called disease 
is not justified by obsenration— that those who pretend to have made a special study of 
the disease, and to have discovered means of cure unknown to the profession, are mere 
pretenders— and that every practitioner is well acquainted with the condition, and fully 
conversant with the treatment that should be adopted. 

Ibis useless to refer to the injuries inflicted by charlatans physically, morally, and 
commercially, because it appears that the law at present affords no remedy. It is a 
disgrace that disgusting hand-bills, headed " Spermatorrhoea," should be thrust into 
the hands of passers by, in all parts of the town ; and that most immoral exhibitions, 
under the title of " Museums," should be permitted to flourish in a city like this ; and 
it is a shame that it should be possible in law for an impostor to mulct a poor, foolish, 
labouring man of £5 and £10 for a dozen bottles of something closely allied to mucilage 
in composition, for the relief of an imaginary ailment. Yet so it is, and without doubt 
will continue. Charlatans, in all departments, well know that obstinacy, indolence, and 
wilful ignorance, form a part of the character of all dupes, and that in all classes of 
civilized society there are always persons with these mental characteristics in sufficient 
number to afford them a favourable reception, to court and patronize them, and to load 
them with flattery and liberal and material support. Quacks well know that when 
their true character is found out, those deceived by them will feel so much ashamed of 
themselves that they have nothing to fear from exposure ; and the utmost inconvenience 
that can ensue to them will only necessitate a change hi the seat of operations. 

It is obvious that the public prosecution of a most extortionate rogue involves the 

. public confession of unutterable folly on the part of the dupe; and although nothing is 

more common than for people to be imposed upon, it is rare indeed for an individual 

to confess that he himself was one of tlie foolish persons who could not see through a 

very transparent trick. 

The diffusion of that which is true can alone enable people to detect what is false, 
and to protect themselves successfully from the imposition of pretenders— medical, 
social, and scientific. 



LIKE SPERMATOZOA. 305 

Rye. Mr. C. Roberts, of St. George's Hospital, has taken very careful 
notes of the case. Some of the bodies in question very closely re- 
sembled spermatozoa; but their true nature was ascertained by 
noticing the character of many other specimens of the vegetable 
growth (Plate XVL, Fig. 82). An account of this case is given in 
the " Archives of Medicine" Vol. I., p. 251. 



Casts of thb Ubinifebous Tubes. 

363. Cajsts of the Benal Tubes are seldom found unmixed 
with other deposits. Frequently they are accompanied with much 
epithelium, and in many cases blood-globules are present in consid- 
erable number. Occasionally, however, we meet with a transparent 
and scarcely visible deposit, consisting entirely of casts. The 
connexion between different renal diseases and the presence of casts 
in the urine has been demonstrated most conclusively by Dr. Johnson; 
many who have not patiently studied the matter, have confidently 
asserted that the characters of casts are not of that importance in 
diagnosis which other observers have maintained. Some, also, even 
go so far as to say that the different morbid states of the kidney, 
familiar to everyone, are but different stages of one and the same 
disease. It is much to be regretted that observation should be 
retarded by hasty and confident assertions of this kind. All that is 
to be said is simply that a few months careful study in the wards of a 
hospital and in the dead-house, will serve to convince any unpre- 
judiced observer that the nature of renal disease may be diagnosed in 
many cases, by the microscopical characters of the urinary deposit, 
and that there are several essentially distinct forms of renal disease. 
I can, from my own observations, testify strongly to the truth of 
the general conclusions arrived at by my colleague, Dr. Johnson, 
upon these questions. 

Of casts there are several different forms, which are to some 
extent characteristic of the morbid changes taking place in the 
structure of the kidney. As has been shown, the cast varies in 
diameter with that of the canal of the uriniferous tube; but 
probably, after its formation, it contracts slightly, and in con- 
sequence it readily passes from the tube, and escapes into the urine. 
If the epithelial layer on the basement membrane of the tube be of 



306 CASTS OF THE 

its ordinary thickness, we shall haye a cast of medium size. If the 
cells be enlarged, and adhere firmly to the basement membrane, 
the cast will be fine and narrow; while, on the other hand, if the 
tabes be entirely stripped of epithelium, the basement membrane 
alone remaining, the diameter of the cast will be consider- 
able. In describing the different varieties of casts it will be 
convenient to divide them into three classes, according to their 
diameter. 

Numerous figures of the various forms of casts are given in the 
" Illustrations of the Urine, Urinary Deposits, and Calculi,^' Plates 
XIV., XV., XVI., XVIL, and XVIII. These figures have been 
traced, from the objects under examination, upon the stone from 
which the plates have been printed. In Plates XVII., XVIII., of 
the present work, and in Plate X., Figs. 50, 51, 52, some variety of 
casts are represented. 

Casts may be divided into different classes according to their 
diameter. The first class of casts, which is by far the largest, will 
include casts of medium size; the second, those of considerable 
diameter; and the third will comprehend the smallest casts that are 
met with. 

A. Casts of medium Diameter, about the l-700th of an inch. 

1. Epithelial casts. 

2. Pale and slightly granular casts, with or without a little 

epithelium, or epithelial dihris. 

3. Granular casts, consisting entirely of disintegrated epi- 
thelium. 

4. Casts containing pus or blood. 

5. Casts containing oil. 

B. Oasts the Piameter of whioh is about tbe l-600th of aji 
inch. 

1. Large transparent " waxy casts." 

2. Large and darkly granular casts. 

O. Oasts tbe Diameter of wMoli is about the 1-lOOOth of an 
inch. 
Small waxy casts. 



URINIFEROUS TUBES. 307 

A. — Casts of Mbdittm Diameter. 

364. Epithelial Casts are met with in great number in all cases 
of acute nephritis; and their presence is generally accompanied with 
a considerable deposit of uric acid, and also with much free 
epithelium and epithelial cUibris, These casts often contain many 
perfect cells of renal epithelium, and not unfrequently blood-globules 
are entangled in them. (^^ Illustrations,^^ Plate XIV., Fig. 1 ; Plate 
XV., Fig. la.; see also Plate XVIII., Fig. 89, of this work.) 

Besides these casts, howeyer, some of the larger casts, com- 
prehended in the second class, may often be observed; and these 
have, as Dr. Johnson states, " a wax-like appearance *' ; or they may 
be dark and granular, or part of the cast may be so highly granular 
as to be quite opaque, while in another portion it may be perfectly 
clear and transparent. The very wide casts and fragments found in 
those cases of acute nephritis, in which the kidney was in a sound 
state before the attack, are probably, wholly or in part, formed in the 
wide portion of the uriniferous tubes near the papilla. Sometimes 
also a few of the small " waxy casts " may be observed, and rarely a 
few of the cells may be found to contain well-defined oil-globules. 

365. Casts oontainlnflr Dumb-Bells.— In the urine of a patient 
suffering from cholera, after eighteen hours suppression of urine, I 
found a trace of albumen, with some very transparent casts 
entangling dumb-bell crystals of oxalate of lime. {^^lUustrationSj^ 
Plate XII., Fig. 1.) Octohedral crystals of oxalate were also present 
in the urine ; but none were to be seen in the casts. The presence 
of dumb-bells in casts proves clearly that these peculiar crystals 
are formed in the uriniferous tube. 

Crystals of triple phosphate and octohedra of oxalate of lime are 
sometimes met with in casts. Not unfrequently perfectly dark casts 
are observed. The opaque appearance is due to the presence of 
urate of soda, which is proved by the fact of the casts becoming 
perfectly clear and transparent upon applying a gentle heat to the 
slide upon which the specimen is placed. (Plate XVIII., Fig. 87.) 
These casts appear white by reflected light. 

366. Casts In Ohroxao Nephritis, a considerable number of 
" granular epithelial casts," of medium diameter, will be present in 



308 CHRONIC NEPHRITIS. 

the early stage of the disease. In the second stage, the granular 
casts become more abundant, and often form a white deposit at the 
bottom of the vessel. 

Dr. Johnson says that, in the third stage, there may be an 
abundant deposit composed of granular casts and disint^rated 
epithelium; or secondly, the granular casts may be mixed with large 
waxy casts, with a sharp and well-defined outline; or thirdly, the 
waxy casts may be in small number, and mixed with a few granular 
casts and disintegrated epithelium. Casts from a case of chronic 
nephritis are represented in Plate XVIII., Fig. 88; see also " lUus- 
trations;' Plate XV., Fig. 2; and Plate XVII. 

867. Oasts oontaiiiiner Oil.— In that condition of the kidney 
termed "fatty degeneration," the pale highly albuminous urine 
which is often passed in considerable quantity, frequently contains 
a number of casts which appear to be made up of oil-globules, or 
composed of cells containing oil (Plate XVIII., Fig. 90). In adults 
recovering from acute nephritis, it is not uncommon to find a few 
oil-particles in the casts, and cells crammed with small oil-globules 
floating in the surrounding fluid; but at the same time, if there be a 
greater number of granular or epithelial casts, the presence of the oil 
need not excite any apprehension for the patient's safety. If, how- 
ever, on the other hand, the oil-casts increase while the other casts 
diminish in number, we shall probably find that the case will become 
one of confirmed fatty degeneration, and that the acute attack 
affected a kidney, not previously in a perfectly sound state. The 
composition of the oil in these cases has been alluded to in § 337. 
{See ''Illustrations;' Plate XVIII., Figs. 1 and 2.) 

368. Fat-Oells. Besides the occurrence of fatty matter in casts, 
and in cells entangled in casts, it is very commonly met with in 
cells, in the urine ; and occasionally these cells are present without 
any casts. They consist usually of epithelial cells of the kidney, 
enlarged and gorged with oil. Sometimes they contain a few oil- 
globules, which are well defined, and are seen to be distinct from 
each other; while, in other instances, the globules are very minute, 
and so crowded together that the cell appears perfectly opaque and 
dark, resembling the so-called ' inflammatory globules.' Although I 
use the term cell, it is not possible in many cases to demonstrate the 



CASTS OF URINIFEROUS TUBES. 
Fig. 83. 



§ § 105, 346 



Fig. 84. 




§§ 105, 346 



Plate xvii. 




Fig. 85. 









X 215 



>%• 



§ 344 



Fig. 86, 







§371 



To face T>agft ^ 



CASTS CONTAINING BLOOD. 309 

the existence of a cell-wall. Occasionally, "cells" containing oil- 
globules may be derived from some other part of the mucous surface 
of the urinary passages. I have seen epithelial cells, and collections 
of oil-globules which have been removed from the membraneous 
portion of the urethra. It is therefore important to bear in mind 
that cells containing oil-globules are occasionally met with in cases 
where the kidneys are not diseased. 

369. Casts oontainingr Blood-Globules are not unfrequently 
met with in the deposit of the urine in acute nephritis. (Plate 
XVIII., Fig. 89.) They are usually of medium size, and often 
contain a certain quantity of epithelium. {^^^ Illustrations,^^ Plate 
XV., Fig. \h.) 

The blood in many of these cases is undoubtedly poured out by 
the vessels of the Malpighian body. It is extraordinary how deter- 
mined some observers are in asserting that this haemorrhage from the 
Malpighian body into the upper part of the uriniferous tube does 
not occur, and that " casts '' are not formed in this part of the tube. 
I have seen the blood in the convoluted part of the tube, near and 
in the Malpighian body, and also in the lower straight portion, on 
several occasions, and I have very often injected colouring matters 
through the capillaries of the Malpighian body into the tube. In 
the newt, (" The Microscope in its Application to Practical Medi- 
cine,^^ p. 225,) the arrangement may be demonstrated beyond the 
slightest question. But Henle ("Zwr Anatomic der Niere,,^^ Got>- 
tingen, 1862) has lately put forward a view upon the structure of 
the kidney, which, if true, completely upsets all that has been made 
out of late years, with regard to the minute anatomy of this organ, 
and necessitates new physiological views; but it seems to me, 
however, that Henle has not satisfactorily proved the facts which he 
has advanced. It may be most positively demonstrated in many 
animals, that Bowman's original description of the course and 
relation of the uriniferous tube and Malpighian body are perfectly 
accurate. I am satisfied that, as yet, no one has succeeded in 
shaking in the least Bowman's original conclusions. Henle's 
drawings seem somewhat roughly executed, and in this particular, 
at least, behind the work of the present day in Germauy. 

370. Casts containing Fob are not common, although some 



810 LARGE WAXY CASTS. 

cells agreeing in character with the pus-globule, in the development 
of two or three little circular bodies in the centre, when acted on by 
acetic acid, are not unfrequently observed. These cells are no doubt 
modified cells of the uriniferous tube. Cases in which the urine 
exhibits these characters are generally acute, and terminate fsitally 
in a short time. A beautiful specimen of the urinary deposit in (me 
of these rapidly fatal cases is represented in Plate XVI. of the 
" Illustrations,^^ see also p. 68. At the same time, I should state 
that I have seen two or three instances occurring in children where 
these casts and cells were most abundant, which have completely 
recovered. 

B. — Casts op oonsidebablb Diambteb. 

871. liorfire Waxy Oa4rts, of about the one-five-hundredth of an 
inch in diameter, are obviously derived from tubes which have been 
entirely stripped of epithelium ; for under no other circumstances 
could casts of this diameter be formed. They are often met with in 
small quantity in the urine of acute desquamative nephritis ; but 
when present in considerable numbers, a condition of kidney to 
which Dr. Johnson has given the name of "waxy degeneration," 
from the peculiar glistening appearance of the substance with which 
the tubes are filled, is present. Large waxy casts are represented in 
the ^^Illustrations,'' Plate XVI., a and 2> ; see also Plate XVII., 
Fig. 86. 

In some cases, however, it is certain that these casts of large 
diameter are formed in the lower part of the straight portions of the 
uriniferous tubes where these are very wide. Often it is evident 
that the material of which the cast is composed is deposited in 
successive layers, and a small cast, formed high up in the convoluted 
portion, is sometimes seen in the centre of a large one formed below. 
In Plate X., Figs. 50 and 51, casts of this kind are represented. 
Although in some cases the convoluted portion of the uriniferous 
tube is wide enough to admit of the formation of one of these large 
waxy casts, I have never seen an instance where the tubes between 
the cortical and medullary portion of the kidney were large enough 
to permit them to pass through. There is, however, no reason why 
this part of the tube should not in some cases of disease, have been 
dilated sufficienty to allow casts of considerable width to pass. {See 
'^Archives of Medicine,'' Vol. I., p. 303.) 



SMALL WAXT CASTS. 311 

C. — Casts of small Diameter. 

872. Small Waxy Casts, on the other hand, are derived from 
tubes in which the epithelial lining is entire, and in which there 
appears no tendency for desquamation to take place — a condition to 
which the name of "non-desqtuimative nephritis'^ has been applied. 
The urine is either found to contain no deposit whatever, although 
albuminous, or only some of the small waxy casts, not more than 
one-thousandth of an inch in diameter, can be found. In some of 
these cases, symptoms of blood-poisoning come on, and a rapidly 
fatal result occurs. The casts have a perfectly smooth and glistening 
surface, and present in the microscope the same general appearance 
as a piece of the elastic lamina of the cornea. {"Illustrations,^* 
Plate XIV., Fig. 6.) It is probable that some of these very fine casts 
come from contracted tubes, and perhaps from tubes which have not 
attained their full development. 

The characters of "transparent mucus casts" have been already 
referred to, and the chemical composition of casts is discussed in 
§ 105, p. 60. 

873. Of Oasts in a Olinioal Point of View. — It is not too 
much to say, that the treatment of renal disease has advanced within 
the last few years more than that of any other class of diseasea 
Frequently we are able to say most decidedly what course should be 
followed in a given case; and we can indicate exactly the conditions 
which will retard the progress of the malady, and warn the patient 
of those which would certainly hasten the extension of disease. I 
do not think I have at all exaggerated the improvement which has 
taken place in this department of medicine ; and when we reflect 
that we possess more positive knowledge of the anatomy and physio- 
logy of the kidney, and that its morbid changes have been more 
successfully investigated than those of other important organs, we 
can scarcely help attributing the improved treatment to our 
increased knowledge, and we have every encouragement to hope 
that ere long a similar result will be seen as distinctly in other 
branches of medicine. I am quite sure that many patients with 
chronic renal disease are now kept alive, and even enjoy life, for 
many years longer than was possible at a time when the exact 
nature of their malady was not understood, and when the treatment 



312 OF CASTS CLINIC ALLY. 

considered right was of a kind which no one, knowing anything of 
the physiology of the kidney, would now think of adopting. 

At the same time we must not express ourselves confidenjj^, if 
only one or two casts of a particular kind are found. Thus w^ may 
meet with, in the deposit of the urine from acute cases, whiplE oobqI^vj: ; 
pletely and perhaps rapidly recoyer, one or two cells containiog c^!/- 
and one or two casts containing a few oil-globules ; but we must not, '^• 
from the presence of these, be led into the error of concluding that the 
case will necessarily become one of fatty degeneration of the kidney. 
If, however, there were numerous cells and casts containing oil, such 
an inference would undoubtedly be correct. We must not expect to 
find in one case epithelial casts alone, in another granular casts 
alone, in a third fatty casts alone, in a fourth none but large waxy 
casts, and so on; but we must be prepared to meet with several 
varieties in one case, and must ground our opinion in great measure 
upon the relative number of any particular kind of cast, and upon 
the circumstance of other deposits being associated with the casts. 
For instance, the presence of uric acid crystals and blood-corpuscles 
would render it very probable that the case was acute, and of short 
duration. The absence of these deposits, and the presence of a 
number of granular or perfectly transparent casts, which can only 
be seen when the greater part of the light is cut off from the field of 
the microscope — or the existence of a number of oil-casts — render it 
certain that the case is chronic. The former would indicate that the 
kidney was becoming small and contracted, while the latter variety 
of casts occurs when it is often of large size and fatty. Such 
examples might be multiplied. When we consider how very 
numerous the secreting tubes of the kidney are, we cannot feel 
surprised that a different condition should exist in certain cases, in 
different tubes, at the same time; and, from careful post-^mortem 
examinations, we know that very different morbid appearances are 
often seen in different parts of the cortical portion of one kidney. 
It is not difficult, therefore, to account for the fact of the presence of 
casts differing much in their diameter and characters in the same 
specimen of urine. 

The treatment of cases of renal disease in which casts are present 
in the urine, has been already referred to in § 257. 



CASTS OF imiNIFEROUS TUBES. 



Plate XVIIl. 



Pig. 87. 







Fig. 88. 






/'■■: 



§ 366 



X 215 



§ 365 



\ "^^'• 




§ § 364, 369 



Fig. 90. 
O 




f 367 



X 215 



Fig 91. 




§372 



X 215 



To Joxitl&«JO«.^V).« 



I 



313 



CHAPTER XV. 



Urine m Disease. III. Of Dense and Opaque Deposits. — 
Pus — Urates — ^Phosphates. — Of Urates — XJrinary Deposits 
associated ivith Urates — Urates in Urine, without forming a 
Deposit: Albumen present — Analyses of Deposits of Urates 
— Of the Clinical Importance of Urates — Of the Treatment 
of Cases in which considerable Quantities of Urates are 
deposited from the Urine. — Pus — Characters of the Urine — 
Tests for Pus — Microscopical Characters of Pus — Of the 
Presence of Pus in Urine, in a Clinical Point of View — 
Of the Treatment of Cases in which Pus is found in the 
Urine, — Earthy Phosphates — IViple or Ammoniaco-Maff'' 
nesian Phosphate — Tests for the Earthy Phosphates — De- 
posits associated unth Triple Phosphate — Phosphate of Lime 
— Phosphate of Lime, in the form of Spherules and small 
Dumb-bells — Of Phosphate of Lime in a Crystalline form 
— Dr» HassaWs Observations on the Crystals of Phosphate 
of Lime — Of the Clinical Importance of Deposits of the 
Earthy Phosphates — Of the Treatment of Cases in which 
Phosphatic Deposits occur — Peculiar Form of Phosphate, 
usually regarded as consisting of Triple Phosphate — On the 
Crystalline Form of Phosphate of Lime, 

IIL— Second Class of Urinary Deposits. 

Substances which are included in the second class of deposits 
form a bulky, dense, opaque, and often abundant precipitate, which 
sinks to the bottom of the vessel, leaying a perfectly clear or more or 
less turbid supernatant fluid. 



314 URATES OF SODA9 AHHONUi 

874. Pas, Urates, Phosphates.— The most important deposits 
of this class are those consisting of urate of soda, pus, and earthy 
phosphate, and these three deposits are very commonly met with. 
To the practitioner, these deposits are especi^Jly interesting ; and as 
their presence in the urine is characteristic of morbid conditions 
differing widely in their results from each other, while the appear- 
ance of the deposits to the naked eye is very similar, it is a matter 
of great importance that he should be able to distinguish them from 
each other with certainty, and at the same time with facility. 
Before entering, therefore, upon a detailed description of these 
bodies, let me draw attention to an exceedingly simple method of 
distinguishing them. The clear supernatant fluid is to be poured 
off, and a little of the deposit transferred to a test-tube. Upon the 
addition of about half the bulk of solution of potash, one of the three 
following points will be noted : — 

1. No change will be produced, in which case the deposit con- 
sists entirely of phosphate. 

2. The mixture will become clear, and very stringy or viscid, so 
that it cannot be poured from the test-tube in drops. In this case, 
we may be certain that the deposit consists of pus. 

3. The solution of potash may cause the mixture to become clear, 
but not viscid, in which case urate of soda and ammonia enter very 
largely into the composition of the deposit. 

If liquor potassaB gelatinises the mixture, but does not render it 
clear, it is probable that both pus and phosphates are present. In 
any of the above instances, our conclusion as to the nature of the 
substance should be confirmed by some of the tests presently to be 
mentioned, and by microscopical examination.^ 

Ubates op Soda, Ammonia, &o. 

876. Urates. — From the researches of Heintz (Lehrbitch der 
Zoochemie) it appears that this deposit, usually termed urate of 
ammonia, really consists principally of urate of soda, with small 
quantities of urates of ammonia, lime, and magnesia. It forms the 

* I have seen, bnt not more than on three or four occasions, deposits of blood and 
deposits of cancer ceUs in snch large quantity, that they might be included in this class; 
but it wonld scarcely be possible, even npon very cursory examination, to mistake 
either of them for pus, phosphates, or urates. Such deposits, in considerable qaantity» 
are not common. For blood, tee $ 416, and for cancer, 1 421. 



91-06 


92-11 


3-78 


6-06 


3-36 


1-61 


1-87 


1-20 



LIME AND MAGNESU. 315 

most common urinary deposit. Heintz and Scherer have shown that 
upwards of 80 per cent, of the lateritious deposit consists of uric 
acid. Heintz finds more than 14 per cent, of soda, and less than 
1 per cent, of ammonia; while Scherer, in three specimens, obtained 
only traces of soda, the ammonia varying from upwards of 2 to 
more than 8 per cent. Much difference exists as to the presence of 
free uric acid in this deposit. According to Heintz, the whole of 
the uric acid is combined as an acid urate, and, as remarked by 
Parkes, the constant proportion of uric acid present in this deposit 
would lead to the inference that it existed in some form of com- 
bination. Bence Jones (^^ Journal Chemical Society ^^ 1862 J found 
the urates in healthy urine to be composed of the following con- 
stituents. Three analyses were made. 

Uric acid . . 94*36 

Potassium . . 3*15 

Ammonium . . 1*36 

Sodium . . . 1*11 

A small quantity of urate is held in solution in healthy urine ; 
and, in slight derangement of certain chemical changes going on in 
the body, it is often secreted in such quantity as to be deposited 
soon after the urine is passed. 

Urate of ammonia, when artificially prepared, crystallises in 
delicate needles; but in this form it is never found in the urine; 
for, as Bence Jones has shown, the slightest trace of chloride of 
sodium causes the salt to assume an amorphous character, and 
increases the solubility of the urate by one-half. Urate of soda is 
sometimes found in the urine, forming globular masses, from 
different parts of which sharp spikes of uric acid project. It is 
probable that these crystals were formed after the globular masses. 
I believe that in urine passed during a feverish state, the uric acid 
crystallises with some organic material which causes it to assume the 
form of spherical crystals. {See the observations on dumb-bells of 
oxalate of lime.) In the urine of children it is very frequently met 
^th in the form of small spherical globules, very like the crystals of 
carbonate of lime from horses' urine, and these sometimes occur in 
the adult. Some of the largest spherules I ever saw, which very 
closely resemble leucine in appearance, are figured in the ^^ Archives 
of Medicine,'' vol. i., p. 249. {See also " Illustrations,'' Plate VIII., 
Figs. 2, 5, and 6.) 

P 3 



316 URINARY DEPOSITS 

In Plate XIX., Fig. 92, some spherules of urate of soda, obtained 
by concentrating healthy urine, are represented. 

Urate of soda is not very soluble in cold, but is readily dissolved 
by a small quantity of warm water, from which, however, it is de- 
posited as the solution cools. It is readily dissolved by alkalies, and 
also by solutions of alkaline carbonates and phosphates. Pure urate 
of soda crystallises in small acicular crystals, which are more or less 
aggregated together. In this form it is found in the pasty deposits 
forming chalk-stones in cases of gout. This thick deposit contains 
much water. In one specimen I examined, the solid matter only 
amounted to 29*9 per cent., and consisted chiefly of urate of soda. 

Deposits of urate of soda vary very much in colour, sometimes 
occurring as the white or pale " lateritious deposit," or " nut-brown 
sediment;" while, in other cases, the deposit has a pink, brown, or 
even dark reddish colour. The amorphous urate is represented in 
the ^^ Illustrations^'' Plate VIII., Fig. 1. Upon the addition of 
moderately strong acids, the deposit of urate is slowly dissolved; 
but, in a short time, a slight granular precipitate may be observed, 
which, upon microscopical examination, is found to consist of rhom- 
boidal crystals of uric acid. It is not uncommon to meet with 
specimens of urate deposit which become decomposed after the urine 
has left the bladder, when numerous crystals of uric acid are de- 
posited. If urate of ammonia be treated with nitric acid, and, after 
evaporation to dryness, ammonia be added, the beautiful purple 
colour, owing to the formation of murexide, is produced. This 
reaction will come under notice when the characters of uric acid 
are discussed (§ 398). Rubbed with caustic lime, a perceptible odour 
of ammonia is evolved. 

376. Urinary Deposits associated with Urates. — The deposit 
of amorphous urate is more frequently accompanied with oxalate of 
lime than with any other salt. It has been shown that urates may 
be readily decomposed into oxalates after the urine has been passed. 
The crystals of oxalate are often so minute as readily to escape 
detection in the abundant deposit of urate, unless the latter be 
dissolved by the addition of a few drops of solution of potash. 2'riple 
phosphate is not unfrequently met with amongst the urate, and 
occasionally a deposit Of phosphate of lime has been observed ; in 
which case the reaction of the urine will be neutral, or even alkaline. 



ASSOCIATED WITH URATES. 317 

Urate of soda is occasionally the cause of the dark granular ap- 
pearance exhibited by some casts of the uriniferous tubes, as may be 
proved by slightly warming the deposit, and then examining it with 
the microscope, when the casts will be found to have become clear. 

877. Urates present without formingr a Deposit: Albumen 
present.— Often the urate remains suspended in the urine without 
forming a visible deposit, and produces a curious opalescence. 
Sometimes the urine resembles in appearance the so-called chylous 
urine ; but its true nature is readily made out by the application of 
some of the tests above referred to. {See also Chylous Urine, § 329.) 
If albumen be present in urine containing urates, it will not become 
clear by heat, or rather, the urine will at first clear, but soon become 
turbid again, in consequence of the precipitation of the albumen. 
With a little care, however, in applying heat, the upper stratum 
of urine in the test-tube may be made hot enough to coagulate the 
albumen, the middle stratum being cleared by the solution of the 
urate without the albumen being thrown down, while in the bottom 
of the tube the deposit remains unchanged. In performing this 
experiment, the test-tube must be held at its lower part. 

878. Analyses of Urine containing: Deposits of Urates. — The 
urine of a child suffering from scarlatina, with delirium and uncon- 
sciousness, contained an abundant deposit of urates. It was acid ; 
specific gravity, 1,025. 

Analysis 66. 
Water 



er . 


9a2-2 




matter . 


67-8 


100- 


Organic matter 


59-03 


87-07 


Fixed salts . 


. . 8-77 


12-93 


Uric acid 


M9 


1-75 



In a deposit which was composed of rounded globules, with small 
sharp spicules projecting from them (uric acid), I found the follow- 
ing constituents : phosphate of lime, urate of soda, and other urates. 
A considerable quantity of these spherules existed in the urine of a 
man sufiering from pneumonia, and they had the following chemical 
characters. There was distinct evidence of the presence of uric acid 
by the murexide test. The deposit was soluble in boiling potash ; 
and when, to the alkaline solution, excess of hydrochloric acid was 



318 OF THE CLINICAL IMPORTANCE 

added, well defined crystals of uric acid were formed. Upon exposure 
to a red heat, an odour like that of burnt horn was exhaled ; s^d, 
after decarbonisation, a moderate quantity of a white ash remained^ 
which dissolved in acids with eflferrescence ; and from the acetic add 
solution a precipitate was thrown down, upon the addition of oxalate 
of ammonia. I conclude, therefore, that urate of lime entered into 
the formation of these crystals. The quantity of crystals at my dis- 
posal was far too small to make a quantitative analysis. 

879. Of the Clinical Importance of Urates. — The amorphous 
deposit of urate is the commonest of all urinary deposits, and, indeed, 
is occasionally present in the urine of everyone, but is much more 
frequently passed by some persons than others. If present in the 
urine from day to day, and especially if it be in considerable quantity, 
it is right to interfere, for it is a clear indication that the chemical 
changes connected with the processes of oxidation are at feult. Im- 
perfect action of the skin, highly nitrogenous diet, little exercise, 
close rooms, too much wine or beer, will almost always cause this 
deposit to appear. In an ordinary cold, the deposit is very generally 
observed. The general conditions which determine the presence of 
an increased quantity of urates are the same as those which cause 
excess of uric acid. But with regard to " excess^^ the observations 
made in § 237 must be borne in mind. There may be a deposit 
without excess, and there may be excess without any deposit whatever. 
Deposits of urates are very common in many cases of heart disease, 
emphysema, and chronic bronchitis. It is probable that the passive 
congestion of the liver and the slow circulation of the blood through 
this organ has much to do with the formation. 

These deposits are almost always present in febrile conditions ; 
and an enormous deposit of urates, sometimes red, sometimes pale, 
marks the occurrence of 'resolution' of many acute inflammatory 
attacks. A "critical deposit of urates" is seen commonly enough in 
acute pneumonia, scarlatina, continued fever, rheumatic fever, &c. 
It need scarcely be said that no special treatment is required to pre- 
vent the formation of the deposit in such a case. In many of these 
acute cases I am in the habit of giving very large quantities of ace- 
tates or citrates. In pneumonia I often give as much as 12 ounces 
of the liquor ammoniae acetates in the 24 hours. "No doubt by this 
treatment many imperfectly oxidised products, and urates amongst 
the number, are eliminated. 



OF DEPOSITS OP URATES, 319 

880. Of the Treatment of Oases in whioh Oonslderable 
Quantities of Urates are Deposited from the Urine. — An 
increased quantity of fluid and a little bicarbonate of potash or soda, 
or liquor potassas, will generally cause the disappearance of these 
deposits. Often the liver is inactive, in which case a small dose of 
calomel or blue pill, muriate of ammonia, or solution of acetate of 
ammonia, will set matters to rights. Some people make themselves 
very nervous about the appearance of this sediment, A little more 
exercise in the open air, moderation in diet, simple food, a little less 
wine than usual, with no beer, and a glass or two of Vichy or potash 
water with the dinner and the last thing at night, will generally 
have the desired effect. All sorts of remedies have been devised for 
the treatment of this condition. Benzoic acid and benzoate of 
ammonia, among other things, have been given with advantage. 

In cases where the ordinary remedies fail, a number of others 
which will suggest themselves to the practitioner may be tried if he 
bears in mind the conditions under which this deposit occurs, and 
inquires carefully into the general habits of the patient. 

Many of the salts of vegetaWe acids do good in cases where urates 
are deposited day after day ; and many fruits, such as apples, straw- 
berries, oranges, lemons, grapes, &a, may be taken. The salts of 
these vegetable acids become converted into carbonates in the 
organism, and they may be given in cases in which alkalies derange 
the action of the stomach. Phosphate of soda is often prescribed, 
and benzoic acid has hem. strongly recommended by-Mr. Ure; but it 
is of the greatest importance, when these depoats are constant, and 
especially when associated with rheumatic pains, to pay attention to 
the action of the skin and bowels. The vapour bath, the hot air 
bath, and the Turkish bath, are of great service by promoting sweat- 
ing. The vapour bath is sufficiently potent, and does not produce 



?UtL 

381. Pus in the Urine is not found in the healthy urine of chil- 
dren and adults, although it is very frequently met with in the urine 
of persons past the middle period of life whose general health is 
good. The changes which occur in the cells of a healthy mucous 



820 PUS IN THE URINE. 

membrane when they give rise to pus-corpuscles instead of to cells 
like themselyes, are now well understood. It is remarkable that such 
a change may take place without the essential purposes of the mucous 
membrane being interfered with. The portion of the genito-urinary 
mucous membrane most frequently affected in this way is undoubtedly 
the urethra, and I believe, next to this, that of the ureters and pelvis 
of the kidney; while the functions of the bladder, as a general rule, 
become seriously deranged before its mucous membrane forms much 
pus. To this last statement there are, however, exceptions. 

The formation of pus-corpuscles in the cells of vaginal epithe- 
lium is represented in Plate XIX., Fig. 98. That an enormous 
quantity of pus may be formed in the pelvis of the kidney and in 
the infundibula without seriously interfering with the general health 
of the patient, is a fact which has been proved by many cases. 
I particularly remember two female patients who, for upwards of a 
twelvemonth, had been passing urine a fourth part of the bulk of 
which consisted of pus. These patients had not suffered in nutrition 
or in general health, and one had gone through her occupation as 
servant during several months. 

The urine of men after the age of forty often contains a greater 
or less number of pus-corpuscles — a fact of which I was not aware 
until I had subjected the urine of a great many hospital patients 
indiscriminately to examination. In private practice the same point 
is noticed very frequently. It is, indeed, more common to find a few 
pus-corpuscles in the urine after this period of life than to find it free 
from them. The fact is important, and shows that the existence of 
pus in the urine must not, per se, be regarded as evidence of serious 
disease. 

Dr. Balfour of Edinburgh has published two cases, in which he 
thinks the pus came from the prostate gland, and considers that it 
is not unfrequently derived from this source in certain cases in 
which it is clearly not formed in the kidneys, ureter, or bladder 
Q^ Edinburgh Medical Journal,''' Vol. 1, p. 612.— 1856.) In con- 
firmation of this conclusion, I may remark that I have often seen 
pus-like cells in the follicles of the prostate, and such cells often 
form the nucleus, around which the hard matter of prostatic calculi 
is deposited. 

382. Oharaoters of the Urine.— Pus generally forms an opaque 



MICROSCOPICAL CHARACTERS. 321 

cream-coloured deposit, which sinks to the bottom of the vessel, the 
supernatant fluid being generally slightly turbid from the presence 
of a few pus-globules. The deposit, however, readily diffuses itself 
again by agitation. The urine will always be found to contain a 
little albumen derived from the liquor puris. If, however, the 
albumen exist in large quantity it is probably derived from the 
kidneys. 

If the urine be alkaline, the pus is no longer present as a cream- 
coloured deposit, but exists as a gelatinous or stringy mass, which 
adheres firmly to the sides of the vessel containing it. It is to this 
glairy mass that the term mucus has been, and even still is, carelessly 
applied. The viscid, glairy, mucus-like deposit arises from the 
carbonate of ammonia, set free by the decomposition of urea, reacting 
on the pus-globules in a manner similar to that in which potash 
behaves. 

383. Tests for Fas. — The tests which may be relied upon for 
detecting the presence of pus in urine, are, the addition of solution 
of potash to the deposit ; and of nitric acid, and the application of 
heat to a portion of the supernatant fluid, in order to detect the 
presence of albumen. Cases from time to time come under notice, 
in which, although the amount of albumen is not great, the quantity, 
nevertheless, appears to be in too large a proportion to the pus-cells 
present, to belong entirely to the liquor puris. In such a case, there 
would be a suspicion of kidney-disease, and the deposit of the urine 
should therefore be very carefully examined for casts of the tubes. 

384. Microscopical Oharacters of Fas. — ^In those cases in which 
the pus is in too small quantity to be detected by chemical tests, we 
must rely upon the microscopical examination of the deposit, and the 
development of two or three small round bodies in the centre of 
each pus-globule upon the addition of a drop of acetic acid. Pus- 
globules always have a granulated appearance in the microscope, 
and, when fresh, do not always exhibit a well-defined nucleus ; the 
outline is usually distinct and circular, but it is finely crenated. 
Upon the addition of acetic acid, the globule increases somewhat in 
size, becomes spherical, with a smooth faint outline ; and from one 
to four nearly circular bodies are developed in the centre of each. 
Pus-corpuscles are represented in Plate XIX., Fig. 93; and in Figs. 

p 6 



822 PUS IN THE URINE. 

94, 96, pus-corpuscles treated with acetic acid, showing the nadei 
very distinctly, are figured. Pus-corpuscles found upon the mucous 
membrane of the urethra, bladder, and vagina, often exhibit little 
protuberances, and these are formed by the moving outwards of the 
living or germinal matter of which the pus-corpuscle is almost entirely 
composed. The nucleus has nothing to do with these vital move- 
ments, such outgrowths often increase, move away from the parent 
mass for some distance, and at length become detached. It is in this 
manner that pus-corpuscles multiply. The process occurs in precisely 
the same way in mucus, young epithelial cells, and in every kind of 
germinal matter. Fus-corpusdes thus increasing, are represented in 
Plate XIX., Figs. 97, 99, under a power of 700 diameters, and in Fig. 
120, Plate XXII., a cell of bladder epithelium is dividing the two. 

886. Of the Presence of Fas in Urine in a ollnioal point 
of view.— From what I have already said it will be inferred that 
the presence of a few pus-corpuscles in urine is a fact which need 
not excite alarm ; that the mucous membrane of the urethra may 
become affected in a slight degree like some other mucous mem- 
branes, and that pus-corpuscles may be formed in small number 
upon its surface, without any material impairment of structure or 
derangement of function resulting. In the urine of the female, it is 
very common to find small quantities of pus which are derived from 
the mucous membrane of the vagina, and in some women the 
formation of pus is almost constant. When, however, pus is found 
in the urine in sufficient quantity to form a deposit visible to the 
naked eye, it should excite our attention. The fact will probably 
bear in a very important manner upon the diagnosis of the case. 
Pus may be derived from any part of the genito-urinary mucous 
membrane; from the surface of the urethra; from the prostate; 
from the bladder, or from the follicles of the mucous membrane in 
these parts ; from the ureters; from the pelvis of the kidney, or from 
the secreting structure of the organ. The pus may also come from 
an abscess opening upon any part of the surface of this mucous 
membrane. 

It is often difficult to form an opinion as to the exact seat of 
formation of the pus ; and it must be obvious that we ought never 
to come to a decision on such a point until we have accurately 
weighed all the evidence that a careful investigation of the case will 



URATES, PUS, &c 



Plate XIX. 



FiA. 92. 




Fig. 93. 



♦.^ 



§ 375 X 215 






§ 384 



Fig. 94. 






^ ^ ^^ 1^ 




1#" ©>*403 



Fig. 98. 



§ 387 



§ 384 



Fig. 95. 



Fig. 9o. 



# * • \ @ 



§ 384 



Fig. 97. 




§ § 355, 384 X 216 



Fig. 99. 




§ 384 X 700 



Fig. 100. 




§ 353 X 215 

To face •paq^.^'i*!. 



u. 



I 

b'1 



CLINICAL IMPORTANCE. 323 

afford. Microscopical examination will give us important help ; but 
we must not rely solely upon this, or indeed upon any single mode 
of investigation. The question is an extensive one, and I shall only 
refer to one or two points connected with the evidence deduced from 
microscopical examination. Some idea of the locality from which 
the pus has been derived may often be formed by examining atten- 
tively the characters of any epithelial cells which may be mixed with 
it (§ 353). When pus is derived from the bladder, it generally con- 
tains crystals of triple phosphate, and granules or small spherules of 
earthy phosphate; and the symptoms of the case will generally 
enable us to decide if the pus be formed in this viscus. Large 
quantities of pus may escape from the bladder for a number of years. 
I know of one gentleman who has passed pus in considerable 
quantity from the bladder during a period of twenty-five years. The 
suppuration of the bladder may be due to gonorrhoea, to gout, and 
to a state of mucous membrane, which is termed catarrh of the 
bladder. It commonly arises from stricture, the contraction inter- 
fering with the free escape of the urine from the bladder, and 
oftentimes preventing the complete evacuation of this organ. If the 
stricture be dilated, the state of the bladder is often completely 
relieved. 

When the pelvis of the kidney is dilated and sacculated (a form 
of pyelitis), the quantity of pus passed in the urine is often 
enormous; and this may last for years, until the kidney becomes a 
mere pus-forming cyst, which, in favourable cases, gradually con- 
tracts, — the formation of pus ceases, — the cyst slowly wastes, — and 
the patient perfectly recovers, — ^the work of the two kidneys being 
performed by the remaining one, which has gradually undergone an 
increase in size corresponding to the increased work it has been 
called upon to perform. When pus is derived from the pelvis of 
the kidney, crystals of earthy phosphates are often absent. I have 
seen five cases of this condition occurring in domestic servants. One 
was under treatment for a twelvemonth, and completely recovered. 
I have now (1863) a case of this disease in the hospital. The girl, 
who is also a servant, has been passing lai^ge quantities of pus daily 
for ten months. The proportion passed in twenty-four hours usually 
occupies the bulk of eight ounces, and sometimes amounts even to a 
larger quantity than this. It is very remarkable in these cases that 
the formation of this large amount of pus is not associated witL 



824 TREATMENT OF CASES 

hectic, and, in many cases, the general health continues good, the 
strength heing supported with tonics and a generous diet. 

There is a chronic state of ulceration of the ureters and pelvis 
of the kidney and bladder, in which pus is formed in considerable 
quantity, leading to the most distressing symptoms. Pus may 
depend upon the existence of old stricture. 

Abscesses form in the kidney as in other organs ; and, after the 
abscess has burst, pus makes its way into the urine. The inflam- 
mation of the mucous membrane of the kidney often extends 
upwards from the bladder. 

The presence of a calculus in the kidney, in the ureter, or in the 
' bladder, may set up inflammation which may go on to the formation 
of pus. A very small calculus will sometimes excite great irritation 
in the kidney, so that both pus and blood are voided in the urine. 

Pus may be derived from a sloughing process going on in the 
kidney. Sometimes a portion of the organ sloughs ofi* entire in 
these cases. My friend, Mr. Newham of Bury St. Edmunds, sent 
me a short time since a piece of kidney which had sloughed ofij 
and passed with much pus into the urine. Pus may also depend 
upon the presence of cancer in the kidney or upon tubercle developed 
in the same situation. 

Pus may come from an acute affection of the uriniferous tubes, 
and the corpuscles will be found free in the urine, and entangled in 
considerable number in casts. These cases are often very rapidly 
fatal. (See " Illustrations;' Plate XVI.) 

Pus formed upon the mucous membrane of the vagina as takes 
place in leucorrhoea has been already considered. 

In women, a large quantity of pus may be formed in burrowing 
abscesses amongst the pelvic viscera, and make its way into the 
bladder, ureters, or vagina. These cases of pelvic cellulitis are not 
uncommon, and I have seen a patient who was reduced to an 
extreme state of emaciation from the long continued drain, com- 
pletely recover, although there were openings, both into the rectum 
and upper part of the vagina, so that sometimes pus passed by the 
bowel, and sometimes it was found in the urine. 

886. Of the Treatment of Oases in which Pas is fonnd in 
the Urine.— The full consideration of this subject, it need scarcely 
be said, would* occupy a volume. I shall, therefore, only allude 



OF PUS IN THE URINE. 325 

briefly to the treatment of some of the cases which naturally fall to 
the province of the physician to treat. But I would remark, 
generally, that the treatment of many cases which are usually con- 
sidered to require special medicines, may be conducted successfully 
upon a much more simple plan than that usually recommended in 
treatises upon medicine. For example, how many remedies have 
been considered specifics in gonorrhoea, and yet the disease very 
frequently gets well very soon under complete rest, mild purgation, 
alkalies, and sudorifics. The most obstinate cases of gleet, which 
have been subjected to various remedies and injections of different 
kinds, often recover if the general health of the patient be improved 
by tonics. The common tincture of sesquichloride of iron and 
quassia persevered in regularly for several weeks is particularly 
valuable in these cases, and it is more than probable that the benefit 
results from the improvement in the general health. 

Among the most obstinate of the conditions which give rise to 
the presence of pus in the urine, is chronic inflammation of the 
bladder, not dependent upon stone. This is often called catarrh of 
the bladder, and, in many cases, is undoubtedly connected with a 
gouty state of system. I have had considerable experience in the 
treatment of this condition, and am satisfied that by far the most 
successful plan is to attend to the general health, and not to trust 
to remedies which are considered to exert a specific action upon the 
diseased mucous membrane. 

Many cases of chronic disease of the bladder that I have seen, 
have been subjected to all kinds of treatment, but not one plan has 
been persisted in for a sufficient time for any benefit to result. A 
patient is ordered, perhaps, uva ursi for a week; then, being no 
better, it is changed to buchu, pareira, or chimaplida, next acids 
are tried with or without some tonic infusion;* then alkalies, and so 
on ; while, in the mean time, the patient has lost his appetite, and 
has gradually got weak, and perhaps has night sweats. As the 
disease continues unabated he begins to lose hope, and suffers more 

* An infosion of the root of common conch grass (triiicum repens) has been strongly 
recommended by Mr. Henry Thompson, as a valuable remedy in cases of irritable 
bladder depending npon varions causes. The proportion is an ounce of the dried 
rhizome to a pint of boiling water. The patient may take from 12 oz. to a pint of the 
infusion in 24 hours. Triticum repens has been incorrectly called the ^ common bind- 
weed," but the plant usually known as "bindweed," is the large convolvulus with 
white flowers {convolmOus tepium,) I have not yet been able to form any conclusion 
as to the value of this remedy from experience, but Mr. Thompson considers it better 
than buchu, and speaks of it in high terms. (^8ee Mr. Thompson's paper in the ^"LarweiJ!* 
October 12th, 1861.) 



826 OF THE TREATMENT OF 

and more from pain and the irritability of tlie bladder. The at- 
tention being necessarily directed to the ailing organ, the condition 
often seems to the patient fan worse than it really is. If unchecked, 
the above-mentioned conditions react upon each other, and the 
patient gets worse. The quantity of pus found in the bladder 
increases considerably, and the calls to micturate are incessant. 

Now, in such a case, it often happens that, if the stomach be set 
right by dilute acids and pepsine — ^if stimulants, which, perhaps^ 
have been withheld altogether, be given in moderation at meals — 
if the diet be simple but nutritious— if the patient take moderate 
walking or carriage exercise in the open air, especially if he be sent 
to a pleasant part of the country, or to the sea-side, where he can at 
the same time be amused — ^if he be ordered the tincture of the 
sesquichloride of iron, beginning with ten drops, and gradually in- 
creasing the quantity to half-a-drachm three times a-day, in infusion 
of quassia, — a great improvement may take place in a few weeks. 
The night-sweats cease, the patient gains in strength and increases 
in weight, and is able to retain his water for three hours or longer, 
while the proportion of pus formed is considerably lessened. I have 
seen patients put upon this plan steadily improve for six months, 
and I have given the iron regularly for a twelvemonth, in some 
cases, with real benefit. In fact it will often happen, that a patient 
will resume the remedy himself, after having given it up, than 
which there can be no stronger evidence of its usefulness. It is 
true that many patients get tired of taking one remedy for so long a 
time, unless the improvement is decided and obvious. It too often 
happens that, by giving way to a patient's caprice in trying this 
thing and that, valuable time is lost. The patient might have been 
relieved, by steady perseverance in a common-sense course, in less 
time than he has spent in trying first one reputed remedy and then 
another, in the hope of relieving, immediately, a chronic malady, 
although it is physically impossible that healthy action can be res- 
tored, except by a very gradual progressive change, which requires 
considerable time for its completion. 

It is clearly right, in such a disease as this, to tell a patient at 
once that he cannot recover in a week ; and it is wrong to allow him 
to think that, by any special remedy, the disease can be cured as by 
an antidote. If patients, who are utterly ignorant of the nature of 
the malady from which they are suffering, will obstinately persist in 



PURULENT URINE. 327 

acting according to their own prejudices, and insist upon being 
misled, to their own detriment, as some undoubtedly will, it is out 
of our power to help them. All that can be said is, that, if they had 
any real knowledge of physiology and medicine, they would have had 
more confidence in us than in an ignoramus who promises a rapid 
cure, and is ignorant of the nature of the disease. 

In all bad cases, more especially if the pus is ever converted into 
the ropy mucus-like mass in the bladder, it is of the first importance 
to use injections of warm water. This is a very simple operation, 
and affords, even in extreme cases which cannot be cured, the 
greatest relief. Some use injections of dilute nitric acid (one drop 
of the strong acid to each ounce of water), but the chief benefit, I 
believe, arises from removing the decomposing matter which irritates 
the mucous membrane and excites decomposition in the fresh urine 
as fast as it reaches the bladder, so that plain water (warm distilled 
or rain water) answers, in almost all cases, perfectly well. It may 
be injected through a double catheter, or through an ordinary ca- 
theter, and drawn off* by the same instrument. The bladder should, 
of course, never be fully injected, os distension of its coats always 
does harm. In bad cases it is necessary to wash out the bladder in 
this, way every day. 

In all cases in which the formation of a considerable quantity ot 
pus goes on in any part of the organism from day to day, it is of the 
first importance to pay attention to the general state of the patient's 
health, and experience has proved that the remedies which do most 
good are those included under the head of tonics. In many cases, 
too, stimulants are required. The quantity of pus varies from time 
to time, and it will be found that it increases if the blood becomes 
poor, while the formation of pus diminishes as the patient^s health 
improves. A greater quantity of material becomes pus when the 
system is weak and low, than when the nutrition of the body has 
improved. This fact has been explained in different ways. It seems 
to me probable that, when the blood is poor, transudation of nutrient 
matters occurs more freely than in the opposite condition ; and it is, 
I think, mainly in this way that iron, many tonics, and alcohol, act 
favourably. The pus grows the faster the more it is supplied with 
nutrient matter, and it takes pabulum which is really required by 
the other tissues. The pus lives faster than any healthy tissue. 

Cases of sacculated kidney require perfect rest, nutritious diet, 



328 OF EARTHY PHOSPHATES. 

and tonics. For the treatment of the different forms of pelvic cel- 
lulitis, I must refer to works upon the diseases peculiar to women. 

The treatment of calculus in the kidney will be discussed in 
Chapter XVIII. 

Deposits op Eaethy Phosphates. 
The earthy phosphates soluble in acids, but insoluble in water 
and alkaline solutions, which are most commonly met with as 
deposits in urine, are, the ordinary triple or ammoniaco-magnesian 
phosphate^ or the phosphate of ammonia and m^agnesia; and the 
phosphate of lime. 

887. Of Triple or Ammoniaoo-lffagfiiesian Fhosphate. — ^The 
triple phosphate crystallises in two or three different forms. The 
most common form is that of the triangular prism, with obliquely 
truncated ends ; but these are sometimes complicated by the bevel- 
ling of the terminal edges. Not unfrequently the crystal is found 
much reduced in length, and the truncated extremities become so 
approximated ajs to give the appearance of a square the opposite angles 
of which are connected by straight lines; and thus an appearance very 
closely resembling that of an octohedral crystal of oxalate of lime is 
produced. Crystals of triple phosphate are very frequently deposited 
from acid urine ; and, when clear and unmixed with other deposits, 
they form a most beautiful microscopic object. (Plate XIX., Fig. 98.) 

888. Tests for the Earthy Fhosphates. — If ammonia be added 
to fresh urine, or to a solution of phosphate of soda and sulphate of 
magnesia, ammoniaco-magnesian phosphate is precipitated in the 
form of beautiful stellate crystals, as I mentioned when speaking of 
healthy urine, and phosphate of lime is thrown down in the form of 
a fine granular amorphous precipitate. 

Ammoniaco-magnesian phosphate is slightly soluble in pure 
water, particularly if it contain carbonic acid. It is insoluble in 
solutions of ammoniacal salts. Heated in the blowpipe flame, 
ammoniaco-magnesian phosphate evolves a disagreeable odour of 
ammonia, and afterwards fuses, producing a whitish enamel. If 
the phosphate of magnesia thus formed be dissolved in a little 
dilute acid, the triple salt may be again formed upon the addition 
of ammonia. The presence of phosphoric acid can readily be proved 
by the appropriate tests. 



PHOSPHATE OF LIME. 329 

889. Deposits associated with Triple Phosphate. — Ammo- 
niaco-magnesian phosphate seldom occurs alone as a urinary deposit. 
Its presence is often associated with urate of ammonia, and some- 
times with uric acid. I have also observed crystals of oxalate of 
lime mixed with those of triple phosphate. In highly alkaline 
urine, it is usually accompanied with pus and phosphate of lime. 

890. Phosphate of Lime occurs commonly as minute granules, 
and small spherical masses or angular particles, and it may also be 
noticed in the form of minute dumb-bells — an appearance probably 
due to the adhesion of two little spherules, which afterwards become 
coated with a fresh deposit of the phosphate. Phosphate of lime also 
occurs in urine in a crystalline form, as was first demonstrated by 
Dr. Hassall. Phosphate of lime is usually associated with the triple 
salt— always, if deposited from alkaline urine. In cases of disease 
of the bladder, in which the urea becomes very rapidly decomposed 
into carbonate of ammonia, much amorphous phosphate of lime and 
crystals of triple phosphate are precipitated. It must not, however, 
be supposed that highly alkaline urine necessarily contains a very 
large excess of earthy phosphate ; for often an excessive quantity of 
the salts have been found dissolved in acid urine, in which case the 
excess can only be discovered by chemical analysia {See Analysis 
44, p. 188.) When the secretion is alkaline, the phosphates are 
always precipitated, and become visible to the naked eye as a 
deposit. 

Phosphate of lime dissolves in strong acids without effervescence; 
and from this solution is precipitated in an amorphous form, upon 
the addition of ammonia. The salt is infusible before the blowpipe, 
unless mixed with triple phosphate; and its fusibility increases 
according to the quantity of the latter. salt present. The lime may 
be recognised in the usual way by the addition of a solution of 
oxalate of ammonia to a solution of the salt in acetic acid. 

Phosphate of lime is soluble in albumen ; indeed, it is by reason 
of its solubility in this substance that the phosphate of lime formed 
by the action of phosphoric acid on the egg-shell becomes applied 
to the formation of the osseous system of the embryo chick. Mucus 
also is a solvent of this salt, and from the mucus of the gall-bladder 
a considerable quantity is deposited as decomposition proceeds 
(Plate XX., Fig. 101). 



880 CRYSTALLINE FORMS 

891. Phosphate of Lime in the Form of Spherules and 
amaU Dumb-bellfk—Deposits of phosphate of lime are generally 
granular; but after a deposit has been allowed to stand for some 
days, little spherules are very frequently found, and it is also not 
uncommon to meet with small dumb-bell crystals. Crystals of the 
latter character are very often deposited in decomposing mucus, 
derived from several mucous surfaces, as well as in that of the 
urinary mucous membrane. Some of the largest of these dumb-bell 
crystals of phosphate of lime are represented in Plate XX., Fig. 102, 
They were found in the urine of a patient suffering ftx)m continued 
fever, under the care of Mr. Carver of Cambridge, who sent me the 
specimen. 

A peculiar form of deposit of earthy phosphate is represented in 
Plate XX., Fig. 103. It consisted partly of phosphate of lime, and 
partly of triple phosphate. There were no true crystals, neither 
was the deposit in a pulverulent form. The little angular masses 
represented, were the only bodies found in this peculiar deposit. 

892. Of Phosphate of Lime in a Crystalline Form.— A phos- 
phate of the form represented in Plate XX., Fig. 104, is not 
uncommonly found in urine. I have not been able to connect its 
presence with any special state of the system, nor to ascertain the 
conditions upon which its deposition depends. It is very frequently 
associated with oxalate of lime, and occurs in acid urine. A con- 
siderable quantity of these crystals were deposited from the urine of 
a man who had a rough oval calculus, composed of oxalate of lime, 
impacted in the ureter. The case is given in Dr. Todd's '^Clinical 
Lectures,^ 2nd ed., p. 562. They were examined as follows : — 

(March, 1851.) " The deposit from about a pint and a half of 
urine was well washed with .water and alcohol, and filtered ; it was 
then dried, incinerated, and decarbonised. The form of the crystals 
had not been materially altered by the ignition ; for, when examined 
by the microscope, scarcely any change could be observed. 

" A portion of the decarbonised crystals were dissolved in dilute 
hydrochloric acid (they were only very slowly soluble in acetic acid). 

" 1. Ammonia and potash produced gelatinous precipitates. 

" 2. Chloride of barium caused a slight precipitate in the acid 
solution ; but, upon the addition of excess of ammonia, a bulky 
white precipitate occurred. 



PHOSPHATES.— URIC ACID. 



Plate XX. 



Pig. 101. 



^ 



90 «. 



§ 391 X 215 



Fig. 103. 



9 391 



Fig. 103. 



«• ^ 

§ 391 X 215 



Fig. 104. 




^L#1>l^ 



X 215 



Pig. 105. 



,1 



^m.^ 

<^--., 

** 
'\\i 



Fig. 106. 



/^ L^^ 







§ 397 



To laxift paQ<i^^^ 



I 



.4U 



OF PHOSPHATE OF LIME. 331 

" 3. After the addition of ammonia and re-solution of the preci- 
pitate by acetic acid, oxalate of ammonia was added, and a white 
granular precipitate was produced. 

" 4. After the addition of nitrate of cobalt and ignition in the 
blowpipe flame, a beautiful blue was given to the mass." This 
reaction usually occurs with phosphate of lime, as well as with 
alumina. These crystals then consisted principally of phosphate 
of lime. 

In another case which I examined, the crystals also appeared to 
consist principally of phosphate of lime. They were dissolved in 
nitric acid, and ammonia added. An amorphous precipitate occurred ; 
but no crystals were formed after the lapse of some hours. After 
separation of the lime by oxalate of ammonia, and filtration, ammonia 
and phosphate of soda were added. A very few crystals of triple 
phosphate formed after the lapse of some time. There was an abun- 
dant precipitate of oxalate of lime. 

In other cases, a phosphate of magnesia seemed to predominate. 
From not being able to make satisfactory quantitative analyses, 
owing to the small quantity of the salt obtained for examination, I was 
unable to determine the exact nature of these crystals. They are, as 
I before said, found in acid urine ; and phosphoric acid, lime, and 
magnesia are present. These are probably the crystals which were 
regarded by the late Dr. Golding Bird as "small calculous concretions 
and simple stellae of the neutral salt." I have seen these crystals in 
urine of persons suffering from no particular malady whatever, and 
I have not been able to connect their presence with any particular 
pathological state. The crystals are not generally found for many 
days together. 

893. Dr. Hassall's Observations on the Crystals of Phosphate 
of Lime. — Dr. Hassall, in an interesting paper published in the 
" Proceedings of the Royal Society'' Vol. X., p. 281, Jan., 1860, 
has stated that phosphate of lime is very commonly found in deposits 
from human urine in a crystalline form. He gives quantitative 
analyses of four specimens of deposit which contained the phosphates 
in the following proportions : — 

Bibasic phosphate of magnesia 0*15 0*47 4*30 
Bibasic phosphate of lime . 1*85 6*18 5*41 1*96 

2-00 6*65 9-71 



332 OF THE EABTHT PHOSPHATES 

This author states that Dr. Golding Bird's "penniform" crystals 
of ammoniaco-magnesian phosphate are really a modification of those 
of phosphate of lime. The crystals represented by Dr. Hassall in 
Fig. 1 appear to be similar crystals to those I have delineated in 
Fig. 35, the chemical composition of which I have alluded to. (See 
also " Illustrations,'' Plate XXII., Figs. 1, 2, 3, 4, 5, 6.) I have never 
obtained these crystals in sufficient quantity for a quantitative exa- 
mination, but have examined several specimens qualitatively, and 
have found that they contained ammoniaco-magnesian phosphate, as 
well as phosphate of lime. The latter was by me erroneously regarded 
as the less important constituent of the crystals, and the form and 
crystalline properties of the salt were referred to the triple phosphate. 
If, however, the crystalline form of the pure salt in Dr. Hassall's 
fourth analysis is represented in his Fig. 1, the composition of these 
crystals is determined, and the phosphate of magnesia obtained in 
some of my examinations must be regarded as an impurity, and not 
as a necessary constituent. 

But Dr. Hassall, in the paper above referred to, goes so far as to 
say " that phosphate of lime, in the form of crystals, is of much more 
frequent occurrence in human urine than the triple phosphate, ex- 
cluding those cases of the presence of the latter phosphate which are 
due to the decomposition of the urea of the urine subsequent to its 
emission " ; and that " granular calcareous deposits are much more 
rare than the crystalline." Now, in these statements, I think he 
will find that few observers will agree with him ; for that the ordi- 
nary crystals so commonly present in the urine, and usually termed 
triple phosphate, are actually composed of that salt, there cannot be 
the smallest question. Crystals of exactly similar form may be 
readily obtained artificially. The salt is easily obtained from any 
urine by precipitation by ammonia, and is often found very nearly 
pure, in large quantity, in urinary calculi. That these crystals, so 
familiar to everyone, are more frequently met with than any other 
form of earthy phosphate, crystalline or non-crystalline, I conclude 
no one will deny. That phosphate of lime often occurs in urine in 
an amorphous form, and not unfrequently in little spherules and 
small dumb-bells, as have been figured; and that, when thrown 
down from its solutions, the deposit is amorphous ; and that in cal- 
culi it is amorphous — are facts generally assented to, and they have 
been repeatedly confirmed. It seems to me that these circumstances 



CLINICALLY. 333 

militate against the conclusion arrived at by Dr. Hassall as to the 
relative frequency of the crystalline forms of phosphate of lime and 
triple phosphate. Nor have I been able to confirm Dr. Hassall's 
observations upon the pathological importance of these deposits of 
phosphate of lime. It is a fact that in the majority of cases in which 
real "excess " of phosphate of lime exists in the urine, it is excreted 
in solution, and does not form any deposit at alL 

Phosphate of lime may be readily obtained in a crystalline form 
by adding a few drops of chloride of calcium to urine (Bence Jones). 
I have succeeded in causing this and many other substances which 
do not readily crystallise, to assume most perfect crystalline forms in 
glycerine. If a little chloride of calcium be dissolved in a drop of 
glycerine, and a little phosphate of soda in another drop, and the 
two drops be allowed to intermix very gradually under thin glass 
upon a slide, most beautiful crystals of phosphate of lime will make 
their appearance in the course of a few days. \ 

On the crystalline forms of phosphate of lime in urine, see also 
the papers of Dr. Bence Jones (" Ghem> Society Trans,,^' 1861) and 
the paper of Dr. Roberts (" Brit, Med, Joum," March 30th, 1861). 

894. Of the Clinical Importance of Deposits of the Earthy 
Phosphates. — The conditions under which an excess of alkaline 
phosphates occurs, have been already considered in Chapter X., and 
I have also referred to cases of molUties ossium, in which an excess 
of the earthy phosphates was excreted in the urine (§ 236). The 
remarks made upon the question of ^^ excess^* of a constituent and its 
precipitation as a visible deposit, must be borne in mind. In the 
great majority of cases in which there is a deposit of earthy 
phosphates, there is no " excess " at all, and the deposition depends 
upon the urine being neutral or less acid than usual, or upon the 
decomposition of the urea, and consequently, the formation of car- 
bonate of ammonia after the urine has left the bladder {See § 382). 
It is common enough to find triple phosphate in the urine in cases 
of dyspepsia, perhaps from the secretion of too large a quantity of 
highly acid gastric juice or from the formation of other acids. 

In various cases of disease, arising from more or less complete 
paralysis of the nerves, owing to changes occurring in the nervous 
centre itself, or at the distribution of the nerves in the mucous 
membrane, the action of the bladder may become impaired and it 



884 OF THE TREATMENT 

may fail to expel its contents completely. The urine thus retained 
sometimes undergoes change in the bladder, and the mucous mem- 
brane suffers in consequence. Earthy phosphate is precipitated, and 
the condition thus induced, without interference, gradually increases, 
leading to the state of bladder referred to on page 324. . 

There are cases in which phosphates are deposited upon every 
part of the urinary mucous membrane, — ^bladder, ureters, and the 
pelvis of the kidneys, apparently depending upon changes which 
result originally from some affection of the nerves. Although the 
formation of epithelium and all the essential phenomena of nutrition 
and secretion may take place, independently of nervous action, it is 
quite certain that the regularity of these changes, the even flow of 
nutrient pabulum, and the regulation of the proper proportion 
distributed, are determined by the nerves. Hence, it follows, that 
if the nerves, distributed to a structure, be destroyed, or their action 
impaired, directly or indirectly, the tissue soon suffers, its structure 
becomes altered, and its function imperfectly performed. 

Some of these cases, perhaps the great majority, are due to local 
disease, for that condition known as chronic inflammation, affecting 
one part of the mucous membrane, is very prone to spread. It may 
extend from urethra to bladder, and even into the ureters and 
pelvis. A rough almost ulcerated state of the mucous membrane 
may spread in the opposite direction — from the kidneys towards the 
bladder. In all cases, the urine in contact with a small portion of 
such altered surface would be decomposed and its earthy phosphates 
precipitated. These, with the epithelium and mucus of the part, 
would form irregular projections and intervening depressions, in 
which more urine would be decomposed ; and so the process might 
proceed, unless the nutritive changes taking place below the surfece 
return to a perfectly healthy state, when the matter deposited would 
soon be thrown off, the even growth of new healthy epithelium would 
proceed below, and the surface would again assume its smooth 
healthy character. For this reason, in such cases, it is of the first 
importance to pay attention to the general health, for it is obvious 
that if the blood be in an unhealthy condition, the action and 
nutrition of the nerve-centres will suffer, in which case, the normal 
state of the mucous membrane cannot be regained. 

Disease of the mucous membrane, and impaired action of its 
muscular coat, also results from disease of the central part of the 



OF PHOSPHATIC DEPOSITS. B36 

nervous system, and some of these cases are among the most dis- 
tressing which the physician is ever called upon to treat. The 
affection begins perhaps in the nerve-cells of the cord itself. These 
gradually undergo change, and many cease to act, or the nerves 
arising from them may be pressed upon or degenerate in structure 
at some distance from their point of origin. Over these structural 
changes we can exert little influence by remedial agents, and as the 
disease proceeds, the state of the patient becomes more painful 
to witness. 

These structural diseases of the cord are of the utmost interest^ 
and their pathology has only very recently been studied. I beg to 
refer the reader to some most interesting and very complete cases 
by my friend, Mr. Lockhart Clarke, in the ^^ Archives of Medidne^^ 
Vols. II. and III. 

395. Of the Treatment of Cases in whioh Fhospliatio De- 
posits oooiir. — When the condition is only temporary, small doses 
of dilute acids in a bitter infusion before meals, or the tincture of 
the sesquichloride of iron, will generally cause the urine to become 
healthy by improving the action of the stomach. Pepsin (§ 316) 
may also be given with advantage in some of these cases. Benzoic 
acid and Benzoate of ammonia have also been prescribed, and sul- 
phate of zinc, extract of nux-vomica, are favourite remedies. If 
the intestinal canal be loaded and the patient have been living 
too well, as is not unfrequently the case, a little blue pill and 
compound colocynth pill will set the patient right. 

Alkalies, as Dr. Owen Rees was the first to show, undoubtedly do 
good in some of these cases of phosphatic urine, probably by their 
action in promoting the normal chemical changes in the blood 
rather than by direct action upon the kidney or any part of the 
genito-urinary mucous membrane. Dr. Kees' explanation has been 
already referred to (§ 200). 

When the phosphate in the urine has persisted for some time, 
and is accompanied with any symptoms referrible to probable 
affection of the cord, especially if the bladder be irritable, and 
there be nervous twitching of the muscles, with tingling or 
numbness of the skin in any part of the lower half of the body, or 
diminished control over the voluntary movements, acids and tonics, 
with small doses of opium, should be given. The practitioner will, 



886 TREATMENT OP PHOSPHATIC DEPOSITS. 

however, meet with many cases in which the symptoms would justify 
him in inferring disease of the cord, nevertheless get quite well as 
soon as the general health is improved. The practitioner before 
treating such cases must find out how the patient lives, and ascer- 
tain if he is suffering from mental anxiety, excitement, over-mental 
work, &c,, and he must avoid giving the patient reason to suspect 
that he thinks he is suffering from any organic disease, for many of 
these patients are terribly nervous, and too prone to dwell upon 
every ache or pain they may have, and are foolish enough to refer to 
medical books, with the view of ascertaining its cause. The diag- 
nosis in these cases should be very guarded, unless the symptoms 
clearly and positively indicate the real nature of the disease. The 
consideration of this extensive subject cannot be further pursued 
here, and I must refer the reader to treatises on diseases of the 
cord. 

The treatment of disease of the bladder, in which the urine 
contains pus as well as phosphate, has been already referred to 
(§ 386). See also Chapter XVIII. on Calculi 



337 



CHAPTEE XVI. 



Urine in Disease. IV. Of Granular and Crystalline De- 
posits, SMALL in quantity. — Urtc Actd — Of the Crystalline 
Forms of Uric Acid — Tests for Uric Acid — Of the Clinical 
Importance of Uric Acid — On the Treatment of Cases in 
which Uric Acid is deposited from the Urine — X,anthine — 
Oxalate of Lime — Octohedral Crystals of Oxalate of Lime 
— Form and Composition of the Crystal^— Dumh-hell Crys^ 
tals of Oxalate of Lime — Of the formation of the Dumb-bell 
Crystals — Of the Conditions under which the Dumb-bell 
Crystals occur — Chemical Composition of the Dumb-bell 
Crystals — Deposits often associated with Oxalate of Lime — 
Of the Examination of Deposits of Oxalate of Lime in the 
Microscope, and of their Chemical Characters — Of Oxalate 
of Lime in a Clinical Point of View — Of the Treatment of 
Cases in which Oxalate of Lime is deposited from the Urine 
— Cystine — Analyses of Urine containing Cystine — Of Cys- 
tine clinically, and of the Treatment of Cases in which 
Deposits occur — Carbonate of Lime — Silica or Silicic Acid 
— Blood-corpuscles — Chemical Characters of Urine contain- 
ing Blood — Of Blood in the Urine clinicaUy — Of the Treat- 
ment of Hismaturia — Circular Sporules closely resembling 
Blood - corpuscles — Cancer -cells — Tubercle- corpuscles — 
Spherical Cells containing Nuclei and Granular Matter — 
Small Organic Globules, 

IV.— Third Class op Ubihtaby Deposits. 

896. TTrio or liithio Acid.— Among the deposits which I have 
arranged in a third class, and which are characterised by their small 
bulk, by their crystalline or granular appearance, as well as by their 



338 CRTSTALUNE FORKS 

density, may be mentioned, in the first place, uric or lUkie add — a 
substance which has before been brought under notice as a con- 
stituent of healthy urine, and of which the chemical properties and 
general characters were then briefly referred to (§§ 135, 213). 
Uric acid forms a crystalline deposit, and perhaps is more frequently 
met with than any other form of urinary sediment, with the excep- 
tion of the urates ; and although there seems reason to belieye that, 
as chemico-pathological investigation advances, we shall no longer 
regard the presence of this, or indeed of any other substance, in the 
urine, as evidence of the existence of a particular diathesis, its 
presence in many cases, especially when the deposit occurs very 
frequently and in considerable quantity, affords an indication that 
the chemical changes in the organism are more or less modified. 

The quantity of uric acid in the urine depends, to a certain 
extent, on the activity of the skin ; and, as a general rule, when 
there is profuse cutaneous perspiration, the amount of uric acid in 
the urine will be found to diminish. If, on the other hand, the 
function of the skin be in any way impaired, or perspiration be 
impeded by cold, a considerable increase in the quantity of uric acid 
will take place. Marcet found that the amount of uric acid dimin- 
ished after severe perspiration; and Fourcroy noticed more uric acid 
in the urine of a man in winter than in summer. In this way may 
be explained the presence of the large quantity of uric acid in the 
urine of persons affected with acute dropsy, or dropsy after scarlatina; 
and it seems probable that the firequency with which these deposits 
are met with in the urine of persons affected with skin diseases 
(especially eczema and lepra) may be due simply to the impaired 
function of the skin. In increased muscular exertion, accompanied 
with imperfect respiratory action, uric acid occurs in abnormal 
quantity. It is present as a deposit in very many cases of chorea. 
It should, however, be borne in mind that uric acid is often dissolved 
in the urine as a urate at the time it is passed, but is afterwards 
precipitated, being perhaps separated from its combination with soda 
(urate of soda) by the process of acid fermentation. 

397. Of the Crystalline Forms of TTric Acid. — In the great 
variety of crystalline forms which uric acid assumes, it is not 
surpassed by any other substance. Its true primitive form is not 
easily determined; but that in which it appears most constantly is 



OF URIC ACm. 

the rhombic, although in many instances this occurs with two of its 
angles rounded. From its salts, however, the acid may be separated 
in rhombic tablets, or in six-sided plates, somewhat resembling 
crystals of cystine, by the addition of acetic, nitric, or hydrochloric 
acid. 

The form of the crystal is much affected by the strength of the 
acid which is added. This subject has been investigated by Dr. A. 
E. Sansom (" Transactions of the Medical Society of King^s College, 
London J Winter Session, 1856-57," p. 128). The following are the 
results: — 

Acid in small quantity . . 5 Crystals regular; mostiy tables and 
^ J ^ squares ; lozenges. 

Acid in large quantity added to j ^ar and long tables, with very 
a strong «>lution of umte of S elongated lozenges, 
ammonia . . . . ) ^* ° 

The various forms which the substance assumes in urine may 
often be traced, by intermediate stages, from one into the other; 
but the conditions which determine the changes have not yet been 
satisfactorily explained. Doubtless the length of time occupied in 
the formation of the crystal has much influence in determining its 
form ; for not unfrequently one crystal is observed to acquire 
entirely different characters if it be allowed to remain for a longer 
period immersed in the urine. Some of the commonest forms met 
with are represented in Plate XL, Fig. 67, and Plate XX., Figa 105, 
106. The most important crystalline forms, besides the rhombic, 
are the rectangular quadrilateral prisms with terminal planes, and 
the dumb-bell crystal. All other forms appear to be some modifi- 
cation of these three. The dumb-bell form of crystals is occasionally 
met with in deposits; but it may often be readily obtained by the 
addition of an acid to urine. These crystals must not be mistaken 
for dumb-bells of oxalate of lime, from which they may be dis- 
tinguished by their large size and darker colour, and by their being 
readily soluble in alkalies. Pure uric acid often crystallises in 
micaceous plates. Uric acid deposited in urine can generally be 
distinguished by its colour from other crystalline deposits, although 
two or three instances have come under my notice in which the 
crystals were found to be perfectly colourless. Various forms of 

Q3 



340 THE CLINICAL IMPORTANCE 

uric acid axe represented in Plate XI., Fig. 57, also in Plate XX., 
Figs. 105, 106; see also " lUustrations;' Plates IV., V., VI., VII. 
A very carious form of crystal is referred to and figured in Plate 
XIX., Figs. 3 and 4, Vol. L of the "Archives of Medieitie,^' 

Uric acid is sometimes deposited very rapidly, when it forms a 
thin glistening film, in which no indication of crystalline form can 
be detected. A film of this kind was brought to me some time since 
by Dr. Chambers. After the lapse of a day or two, well marked 
crystals made their appearance. Some of these films are composed 
of layers of small crystals, closely matted together. After the lapse 
of a short time, the larger crystals grow, while the smaller ones 
disappear; so that at length a number of large well-defined crystals 
are produced. 

A deposit of uric acid sometimes resembles amorphous urate, and 
even under very high powers of the microscope nothing but minute 
granules can be detected, even for some hours after the urine has 
been passed. This deposit is not soluble in boiling water, and in the 
course of from 24 to 48 hours the granules will be found to have 
increased considerably in size, while many exhibit well-defined crys- 
talline form. 

308. Tests for XTric Acid.— When we are in doubt as to the 
nature of a deposit suspected to consist of uric acid, we may examine 
it as follows. If it consist of uric acid, it will be insoluble in hot 
water, but soluble in alkalies, potash, soda, and ammonia. 

1. A portion of the deposit is to be dissolved in a drop of potash. 
The alkaline solution is then to be treated with excess of acetic acid. 
After the lapse of a few hours, crystals of uric acid will be formed, 
which must be subjected to microscopic examination. 

2. A sediment, suspected to be composed of uric acid or a urate 
may be placed upon a glass slide, and treated with a drop of strong 
nitric acid. After evaporation to dryness at a gentle heat, the slide 
is to be exposed to the vapour of ammonia, or a drop of ammonia 
may be added to the dry residue. A beautiful violet colour, owing 
to the formation of murexide, proves the presence of uric acid or a 
urate. 

300. Of the Olinical Importajioe of XTric Acid.— This sub- 
stance exists in the blood, in combination with a base, as an alkaline 
or earthy urate, which is comparatively soluble. The soluble urate 



OF URIC ACID. 841 

may be decomposed; 1, when it arrives in the uriniferous tubes; 
2, subsequently, when the urine reaches the bladder ; or, 3, as more 
commonly happens, the acid may not be set free until some time 
after the urine has been passed. 

In the first case, the acid may accumulate and block up the 
tubes, or perhaps form a small concretion; but, as I shall show in 
the next chapter, oxalate of lime very frequently forms the real 
nucleus of these uric acid calculi which are so common. In the 
second case, if a small concretion of any kind exist in the bladder, 
uric acid is deposited around it, and a uric acid calculus becomes 
rapidly formed. The deposition of uric acid after the urine has been 
passed is often merely accidental, and depends upon the decomposition 
of the urates by a process of acid fermentation, which has been fully 
investigated by Scherer. The acid crystallises sometimes very soon 
after the urine has been voided, sometimes not for some days after- 
wards. I have before alluded to the importanco of not regarding 
the deposition of uric acid crystals as m all cases depending upon 
excess of the acid in the urine. There may actually be less uric acid 
than is present in health, although it may be deposited entirely in 
an insoluble form. 

I may state generally, that we are likely to meet with this 
deposit in cases where a liberal meat diet is indulged in by those 
who take very little exercise; and in the urine of people who lead 
very sedentary lives, it is not uncommon. In various gouty affections 
it is very frequently observed. In diseases of the liver, it is 
especially common; and temporary congestion of that organ is very 
frequently associated with the presence of much uric acid in the 
urine. In chronic diseases of the respiratory organs, we often meet 
with uric acid and urates in the urine. It is common in emphysema 
of the lung, and in chronic bronchitis. In pneumonia and rheu- 
matic fever, it is often found. It is seldom absent from the urine in 
chorea, and very often exists in various forms of skin-disease, and in 
cases of acute inflammation of the kidney. It is occasionally met 
with in diabetes. 

There are many cases in which the tendency to deposits of uric 
acid is not very easily explained. Some children are very liable to 
suffer from uric acid deposits, and their appearance is accompanied 
by frequent desire to pass urine. In cases where the deposit is very 
frequent it is necessary to interfere. 



342 TREATMENT OF 

I have seen instances of uric acid deposits, occurring in adults in 
which ordinary remedies appeared to exert no effect. The urine of 
a patient suffering from emphysema of the lung always contained a 
large quantity; and it appeared while she was taking considerable 
doses of alkalies, and also when she was put upon mineral acids. 
The connection between deposits of uric acid and gout has been 
referred to in page 163. 

400. On Uie Treatment of Gases in which XTric Acid is 
Deposited in the Urine.— Occasionally we meet with patients who 
appear generally in good health, but who complain of getting thin, 
although they live well, in many instances perhaps too well, and 
suffer from an almost constant deposition of uric acid. It is very 
difficult to explain this symptom in every case in which it occurs ; 
but I feel sure that many of these persons overtax their digestive 
organs, and are in the habit of oating ioo muoh. They think thiit 
the only way to gain flesh is to consume a large quantity of food ; 
and, in consequence of too much work being thrown upon their 
digestive orgians, especially the liver, assimilation is not properly 
carried on, and a quantity of material is formed which is unfitted for 
the wants of the organism, and is perhaps got rid of in the state of 
urea, uric acid, and urates. By cutting off a certain part of the supply, 
their anxiety as to the gravel is soon relieved, and at the same time, 
to their surprise, they gain strength and increase in weight. 

I have already alluded to the great objection of employing 
the term "uric add diathesis" (page 141), and have referred in 
§ 214 to the general principles which should guide us in the treat- 
ment of cases in which an excess of uric acid is eliminated in the 
urine. The occasional deposition of uric acid crystals from the urine 
requires no medical treatment, or at most a dose of bicarbonate of 
potash after meals or the last thing at night. In some cases 
in which these deposits are frequent, and in people of a gouty ten- 
dency, small doses of hydrochloric acid with pepsin, before meals, 
and twenty grains of bicarbonate of potash, in half a tumbler of 
water, after meals, is a plan which answers admirably. 

401. Xanthine (C^ANfO) or Uric or Xanthine Oxide is a 
substance closely resembling uric acid in many of its characters. It 
is very rarely met with in urine. It was described first by Marcet, 
and has since been detected in the blood, and also in the spleen, 



URIC ACID DEPOSITS. 343 

muscles, liver, and brain. It is rarely met with in the crystalline 
form, but Bence Jones reports the case of a boy, aged 9^ years, in 
whose urine xanthine crystallised in lozengenshaped crystals, which 
were first mistaken for uric acid. The deposit disappeared on 
boiling the urine, and was soluble in water, nitric, and hydrochloric 
acids, and in alkalies (quoted by Hassall). Douglas Maclagan also 
reports a case in which xanthine occurred in a urinary deposit. 
Xanthine is probably a common constituent of urine, but exists in 
very small quantity. A rare form of calculus is entirely composed 
of it. Xanthine is stated by Dr. John Davy to be the principal 
constituent of the urine of spiders and scorpions. 

Oxalate or Lime. 

The next substance which is to be noticed is oxalate of lime, 
which was first shown to be a common urinary deposit by Dr. 
Golding Bird. It is seldom deposited in quantity sufficient to be 
recognised by the unaided eye, or to be subjected to chemical 
examination. 

402. Ootohedral Orycitals of Oxalate of lilme.— This salt 
crystallises in well-defined octohedra, having one axis much shorter 
than the two others. The crystals vary much in size, and two or 
three forms have been described by authors. In the cases I have 
met with, the difierent appearances of the crystals were due to the 
position in which they were viewed, as may be readily proved if a 
little glass model be constructed. The flattened octohedron is 
obviously the most common appearance, because the crystal lies most 
easily on one of its faces. If, however, it be turned with one of the 
long axes directed towards the observer, while the other is held 
upright, the short axis will necessarily be transverse, and the crystal 
will appear as a long and very acute octohedron (Plate XXI., Fig. 
107, a). If now one of the lines formed by the meeting of two oppo- 
site faces be turned towards the observer, there will still be the 
appearance of an acute octohedron; but it will be less acute than 
before, and no transverse line in the centre can be made out. Upon 
keeping the same line towards the eye, and by carefully turning the 
crystal, so that the two opposite faces are made quite parallel to each 
other, the appearance as of a long-shaped four-sided crystal will be 
produced. The difierent appearances produced by viewing the same 



344 OCTOHEDRA OF OXALATE OF LIME. 

crystal in different positions are represented in the " lUustrationt,^ 
Plate XI., Fig. 1, a, b, o, d, e. Crystals in all these different positions, 
appearing as different forms, are commonly met with in the exami- 
nation of urinary deposits. In Plate XXI., Figs. 107, 108, are 
represented octohedra in yarious positions, dumb-bells, and circular 
and oval crystals of oxalate of lime, with two cells of bladder 
epithelium, deposited from the urine of a patient suffering from a 
tense state of the skin of the wrists and arms, a condition which is 
sometimes termed "hide-bound." 

Many observers have figured these crystals incorrectly. Dr. 
Golding Bird considered that they belonged to the cubic system. 
Dr. Prout, however, has given a figure of oxalate of lime which 
clearly shows that he was aware of the exact form of the crystal. 
Prismatic crystals of oxalic of lime occur in some plants, and they 
have been observed by Beneke in urine. I found that some 
preparations of ordinary oxalate of lime, which had been kept for 
some years in preservative fluid, underwent a change in form, and 
were at length entirely replaced by beautiful prisms. Plate XXI., 
Fig. 109, represents a rare form of crystal. The extremities 
resemble the two faces of an ordinary octohedron, but they are 
separated by an intervening quadrilatenil prismatic portion. 

Oxalate of lime may be obtained in its usual octohedral form 
from its solution in hydrochloric acid ; and Neubauer states that 
from a solution in phosphoric acid, crystals may be obtained by 
neutralising the acid by soda or potash. 

Dr. Thudichum has carefully examined the form of crystals of 
oxalate of lime obtained in different ways, and he brings all the 
different forms he has observed under the following heads : quadratic 
octohedron, crossed octohedra, quadratic octohedron and prism 
combined; crossed prisms; triple twins, with tropia; modifications 
of crossed octohedra; contortions and anomalies, including dumb- 
bells. He also shows, contrary to previous statements, that the salt 
actually possesses a polarising power, as should be the case if it 
belongs to the quadratic system. This is, however, difficult to 
demonstrate, and can be only brought out fully by reflecting a ray 
of the sun through the crystal, which accounts for the fact having 
escaped observation. I had long ago examined crystals by the 
polariscope which had been mounted in Canada balsam, and had 
noticed that they were often slightly illuminated when the field was 



OXALATE OF LIME.-BLOOD CORPUSCLES. PLATE XXL 



Fig. 107 



Co ® 



^ 




% 402 



X 2U 



Fig. lOS. 






§402 



Fig. 109. 



m 



§ 402 



Fig. na 










«^0 



$403 X 215 




Fig. m. 



f.^0 



l>'^ 
^^% 



00 

pt3 



^<3? 



0<C>' 












§ 416 







§ 403 



Fig. 113. 

•o o 
§ 403 



2V>/«ce'pogft'3;^. 



DUMB-BELL CRYSTALS. 345 

dark. Althongh I had figured the form of the crystals correctly, I 
must confess that I was too ready to agree with the statements made 
by others as to the system to which this crystal belonged ; nor was I 
sufficiently acquainted with crystallography to discuss this question 
fully. In this matter Dr. Thudichum has corrected me ; and, after 
a re-examination of the question, it is only right that I should state 
that the octohedra, mounted in Canada balsam, do polarise even with 
a good artificial light ; and therefore no argument in favour of the 
dumb-bell crystals being composed of oxalurate, and not of oxalate of 
lime, can be based on the statement that the octohedra do not polarise. 

408. Dnmb-bell Orsrstals of Oxalate of liixne. — Oxalate of 
lime, however, occurs more rarely certainly, but still not uncom- 
monly, in another very interesting form, which was first pointed out 
by Dr. Golding Bird. From their resemblance to dumb-bells, these 
bodies are known as the dumb-bell crystals of oxalate of lime. 
Dr. Golding Bird thought that they were composed of oxalurate, and 
not of oxalate of lime ; but the following points, in addition to what 
has just been stated, render this very improbable. 

1. Octohedra, in all the cases I have observed, were deposited from 
the specimen of urine in which the dumb-bells were found, and in- 
variably precede and follow the appearance of the dumb-bell crystals. 

2. Minute calculi are often composed of dumb-bells, as may be 
shown by microscopical examination ; and these calculi have been 
proved by analysis to consist of oxalate of lime. 

Organic matter exists in every part of the dumb-bell. By the 
prolonged action of acetic acid the crystalline material is dissolved 
out, leaving this organic matter. Mr. Rainey has shown that the 
presence of viscid organic matter prevents crystalline substances 
from assuming their usual form, and causes the crystalline material 
to be deposited in the sperical or dumb-bell form. Now when the 
crystalline matter is dissolved out the organic basis remains, and its 
sharp outline looks like that of a cell-wall (Plate XXI., Fig. 112). 
The appearance of a cell-wall may be observed, if the earthy salt from 
the spherical and dumb-bell crystals of carbonate of lime in horses* 
urine be dissolved out by an acid. The same point may be demon- 
strated upon a larger scale by treating the small phosphatic calculi, 
sometimes found in the kidney in considerable number or prostatic 
calculi, with dilute acid. In all these cases the outline of the 

q5 



346 THE FORMATION OF 

transparent matrix gives the idea of a hollow transparent membrane 
or celL A spherical mass of jelly or any other transparent solid 
substance would exhibit a similar well-defined outline. This sharp 
line has been accepted as eyidence of a cell-wall in innumerable 
cases where no such structure really exists. 

Some persons have stated that these dumb-bell crystals of oxalate 
of lime were composed of uric acid — ^a mistake for which it is 
very difficult to account, since, in their optical characters and 
chemical properties, they widely differ. The uric acid dumb-bell 
is instantly dissolved by dilute potash, and, by the addition of 
excess of acetic acid, rhombic crystals will be thrown down; while 
the dumb-bell of oxalate of lime is insoluble in a strong boiling 
solution of potash. 

Besides the dumb-bell, it is common to meet with a number of 
closely allied forms, among which may be mentioned circular and 
oval crystals. (" llltistrations,'' Plate XI., Fig. 2, a, b, c, d, e,f,) 
In several of the cases which have fallen under my notice, the true 
and perfectly shaped dumb-bell was preceded by circular and oval 
crystals; and these also again appeared after true dumb-bells could 
no longer be detected in the urine. These crystals often disappear 
the day after multitudes have been found ; and generally they are 
only noticed for a few consecutive days — a circumstance which may 
perhaps account for the comparatively few instances in which these 
crystals have been noticed. Two or three oval crystals are seen in 
Plate XXI., Fig. 107. 

404. Of the Formation of the Dumb-beU Crystals. — It is 
well known that the octohedra of oxalate of lime are commonly 
deposited in the urine after it has left the organism; and if urine 
which contains very minute octohedra be allowed to stand for a few 
days, these may often be observed to increase in size, until at length 
they became very large crystals, while at the same time a number of 
new ones are developed. On the other hand, dumb-bell crystals are 
present in the urine when it is passed, and they do not increase 
in size or number if allowed to remain in it. These dumb-bell 
crystals are formed in the renal tubes. I have found them entangled 
in casts in the urine of a cholera patient passed after eighteen hours 
complete suppression during the stage of collapse. The specimen of 
urine in which these casts were found was very acid, of a dark colour, 



DUMB-BELL CRYSTALS. 347 

and specific gravity 1024. The urine contained no albumen. The 
following report was made at the time of examination. Deposit very 
slight, consisting of transparent, smooth, and hyaloid casts, for the 
most part homogeneous, but in a very few of them a small quantity 
of granular matter was observed. In others, dumb-bell, oval and glo- 
bular crystals of oxalate of lime were noticed. The dumb-bell crys- 
tals were seen only in the casts, but many octohedra were observed 
in the surrounding fluid. {^^lUustrationSf' Plate XXII., Fig. 1.) 

I have seen many times a number of dumb-bells impacted in the 
tubes of the kidney, especially in the pyramids. Indeed, if thin 
sections of this portion of human kidneys be made, these dumb-bell 
crystals will be observed not unfrequently. Often several may be 
seen in the wide portion of the tube, just before it opens upon the 
surface of the mamilla. 

It is probable that were octohedral crystals appear to be in casts, 
they are really deposited upon the surface or in the substance of the 
cast, some time after the urine has left the bladder. 

405. Of the Oonditions tinder which Dumb'^bell Crystals 
occur. — I have met with a great many specimens of urine containing 
dumb-bells, but have been unable to associate the appearance of 
these crystals with any particular morbid condition. It may be 
interesting to refer to a few of the cases which occurred in the 
hospital some years ago. During six months, I met with ten or 
eleven cases, in which these peculiar crystals were present, out of 
about four hundred cases in which the urinary deposit was examined; 
but I have not observed that the urine containing them possesses 
any characters by which we might be led to suspect their presence, 
before resorting to microscopical examination; and, from my own 
observations, it does not appear that the dumb-bells are connected 
with any peculiar form of disease, or with any particular diathesis. 
They occur usually mixed with the ordinary octohedra of the oxalate, 
but I have found them alone; frequently they are found accompanied 
with urate of ammonia and crystals of uric acid, and often with both. 
Out of ten cases in which they were present, eight were men, and 
the remaining two were women, above the age of 21. Of these ten 
cases, nine occurred between the months of September and January, 
and one in April ; but this may be accounted for by the fact, that 
during the winter I have always made a much greater number of 



348 DUMB-BELL CRYSTALS 

microscopical examinations than during the summer months. It 
may prove interesting to give a list of the cases in which these 
dumh-bell crystals, or crystals allied to them in form, occurred. 
They were present in- 
One case of chorea. 

Two cases of cholera. 

One case of chronic rheumatism. 

One case of contraction of the skin of the neck and upper extre- 
mities, the condition to which the term "hide-bound** has 
been applied. 

One case of boils, occurring in various parts of the body. 

One case of paraplegia, depending upon diseased vertebraB. 

One case of attempted poisoning by taking half an ounce of 
oxalic acid. 

One case of eczema. 

One cage of epilepsy. 

Out of these ten cases, in which the dumb-bell forms of crystal 
were present, it will be observed that only two instances occurred 
in which they were found in the urine of patients afllicted with a 
similar disorder, and it is somewhat curious that these should be 
cases of cholera. The other cases differ so entirely in nature from 
each other, that one cannot conclude that this curious form of crystal 
is in any way dependent upon the nature of the malady, but we are 
rather led to the conclusion that these crystals arise from certain 
conditions unconnected with any particular disease. The dumb-bell 
crystals often occur in the urine of persons not suffering from any 
special disorder at all, who consider themselves in good health ; but 
generally there is languor and loss of appetite, with uneasiness after 
eating, and the individual, without being able to give an account of 
any particular ailment, complains of not being quite well. Dumb- 
bells often occur in cases where little exercise is taken, with a full 
diet, and too little water. The concentration of the fluids, and 
imperfect oxidation, will fully account for the formation of these 
crystals in cases of cholera; and it is probable that similar con- 
ditions are present to a less extent, and owing to a different cause, 
in other cases in which dumb-bell crystals have been detected. 

Sometimes several dumb-bells adhere together, forming an irregu- 
larly-shaped mass, which gradually becomes smooth by the deposition 
of the same material in the interstices, until a small, nearly spherical 



OF OXALATE OF UlfE. 349 

or oyal, mass is formed. {See Fig. 125, Plate XXIII.) In other cases, 
it would appear that one or two crystals grow at the expense of the 
rest, and a perfectly uniform oval crystal, composed, of course, of 
numerous acicular crystals, radiating from a common centre, results 
(Fig. 124). Thus the dumh-hell crystal hecomes the nucleus of a 
small calculus, and it is easy to see how this may increase in size by 
the deposition of new matter externally — at first, while it remains 
in the straight portion of the uriniferous tube, or in that system of 
irregularly-shaped cavities at the apex of the mamilla, formed by the 
convergence of several of the large tubes ; then in the pelvis of the 
kidney or ureter ; and, lastly, in the bladder itself. 

406. Ohemical GompositiozL of the Dumb-bell Crystals. — 

The chemical composition of these crystals has long been a matter of 
dispute among chemists, but it may now be regarded as nearly certain 
that they consist of oxalate of lime ; for since it has been shown that 
the dumb-bell may gradually grow into a small calculus, and that 
the latter is composed of oxalate of lime, we are certainly justified in 
inferring that the dumb-bell or microscopic calculus has the same 
chemical composition. No difference in chemical character, refractive 
power, or in the action of polarised light, can be detected between 
the minute dumb-bell or oval crystals, and the aggregations of dumb- 
bells which are from time to time met with forming microscopic 
calculi. There cannot, in fact, be the slightest doubt of their being 
the same substance in different stages of deposition. Kor can there 
be any question of the latter being, in their turn, an early condition 
of the small renal oxalate of lime calculi. In very many instances 
the nucleus of a uric acid renal calculus consists of oxalate of lime. 

407. Deposits associated with. Oxalate of Llzae. — Oxalate of 
lime is often found associated with other deposits, particularly with 
urate of soda, in which case the minute crystals are easily passed 
over amidst the amorphous deposit. The peculiar form of crystals 
of earthy phosphate described in § 392, are usually found in urine 
from which oxalate of lime is also deposited. 

Crystals of oxalate of lime are so minute that, without care, they 
may be readily passed over in a microscopical examination; and very 
frequently the only appearance observed in the microscope is the 
presence of clusters composed of minute cubical or square-shaped 
crystals, which appear almost opaque. Indeed, such clusters of 



350 OF OXALATE OF LDIE. 

oxalate of lime crystals may be easily mistaken for urate of soda, 
from which, however, they may be readily distinguished by the fact 
of their not being dissolved upon warming the slide, and by their 
insolubility in potash and acetic acid. Crystals of this character 
are often found adhering closely to hairs and other substances. 
Deposits of oxalate of lime and uric acid are represented in the 
" lUustrationSf'' Plate XXI., Figs. 6 and 6 ; and of oxalate of lime 
and phosphate, Plate XXII., Figs. 6 and 6. 

408. Of the Examination of Deposits of Oxalate of I<ime by 
the KCicroscope, and of their Chemical Characters. — The larger 
crystals are readily recognised by their microscopical characters; and 
the only crystals I have known mistaken for them are crystals of 
triple phosphate, as I mentioned when speaking of the phosphatic 
deposits. If, however, there be any difficulty, a drop of acetic acid 
will soon set the question of the composition of the crystal at rest. 

Oxalate of lime deposits seldom sink to the bottom of the vessel 
in which the urine is placed, but seem to be buoyed up by the slight 
mucus deposit present. When, therefore, a drop of urine is taken 
for examination, there is no necessity for taking it from the very 
bottom of the vessel, the stratum of fluid slightly above this point 
being often richer in crystals. 

Oxalate of lime seldom occurs in urine in sufficient quantity for 
chemical examination. If oxalate of lime be burnt in a platinum 
capsule, and the carbonised residue be exposed for some time to the 
dull red heat of a spirit-lamp or other flame, a white deposit will 
remain, which will be found to be insoluble in water, but it will be 
dissolved in acetic acid with copious effervescence, showing that, by 
the process of combustion, the oxalate has been converted into car- 
bonate. If, however, the carbonate has been exposed to a bright red 
heat, there will be danger of its partial or complete conversion into 
lime, in which latter case no effervescence will occur upon the addition 
of an acid. In the acetic acid solution, the presence of lime may be 
detected upon the addition of oxalate of ammonia, oxalate of lime 
being quite insoluble in acetic acid. 

409. Of Oxalate of Lime in a Clinical Point of View.— There 
is still much difference of opinion among practitioners as to the 
clinical importance of oxalate of lime. There can be no doubt that, 
in the majority of instances, the crystals form after the urine has left 



GUNICAL IMPORTANCE. 351 

the bladder; and there is good reason for believing that the oxalic 
acid is often produced by decomposition of the urates after the urine 
has been passed. The experiments of Dr. Aldridge, of Dublin, show 
that uric acid and urates are easily decomposed into oxalic acid and 
oxalates. Dr. Owen Eees entertains the opinion that this substance 
is derived from the urates, and that, when present in the urine, it 
indicates the existence of urates in the blood. Oxalate is often 
deposited in the urine of gouty cases, and it is certainly very often 
found among urate deposits. Although there are certain conditions 
of the system in which both oxalates and urates are very common, 
both deposits may be present — ^indeed very commonly are present — 
in the urine of healthy persons. Hence it is obvious, that the 
presence of such deposits is no indication of the existence of any 
particular diathesis. The fact seems to be rather, that, in what is 
termed the '^oxcdio diathesisy^ among other symptoms, oxalate of 
lime is present in the urine; but this is not the most important 
symptom, and the practitioner cannot make a greater mistake than 
to direct attention, in such a case, to the urinary deposit alone, or 
consider this the most important indication for treatment. In the 
same case, at one period, we may find uric acid and urates; after a 
time, these mixed with oxalates; and, lastly, they may give place to 
a deposit of oxalate alone. 

Wohler and Frerichs injected uric acid into the blood of a dog, 
and found oxalate of lime in the urine. Oxalate of lime passes 
through the alimentary canal unchanged ; but oxalic acid is in part 
excreted in the urine, while part is decomposed in the system. 
Bucheim and Fiotrowsky have shown that small repeated doses of 
oxalic acid (fifteen grains every hour for six hours) are not poi- 
sonous. Kot more than 12 per cent, of that taken by the mouth 
appears in the urine. I have detected oxalate of lime in the urine 
of several persons who have attempted to poison themselves with 
oxalic acid. 

Oxalate of lime is, however, not always formed after the urine 
has reached the bladder. I have shown that there is very strong 
evidence of its deposition in the tubes of the kidney in certain cases, 
in the form of dumb-bell crystals ; and it must therefore have been 
formed at the time of the separation of the urine from the blood, if 
it did not exist in solution in the blood itself 

It appears, then, that oxalate of lime may be excreted in the 



352 OXALATE OF UME. — TREATMENT. 

nrine when oxalic acid or oxalates are taken in the food. It may he 
formed in the organism itself; and it may he produced hy the 
decomposition of uric acid and urates after the urine has left the 
bladder. 

Beneke has shown that the earthy phosphates and oxalates 
increase in direct proportion to each other. The nutrition of the 
tissues generally would he impaired under the same circumstances; 
and a larger amount of earthy phosphate would pass off in the urine 
dissolved hy the oxalic acid. {"Archiv, des Vereins" Band I., 
Heft. 3.) 

It must he borne in mind that oxalate of lime is often discovered 
in almost opposite conditions. Thus it is sometimes present in poor 
broken down subjects, and it is found in the urine of well-to-do 
country gentlemen. It will appear when we live too well and take 
too little exercise. It is common in chronic pulmonary affections, 
as bronchitis ; and it is often observed in old cases of emphysema. 
It is common enough in dyspeptics, and is usually met with in cases 
of jaundice. In various forms of general debility, in cases of over- 
fetigue, and in men who have overworked their minds, it is perhaps 
the commonest urinary deposit. Lastly, I have found it many times, 
and in very large quantity, in the urine of men who appear in all 
other respects in perfect health. 

410. Of the Treatment of Cases in which Oxalate of lazae 
is deposited from the TJrine.— The remarks made in the last sec- 
tion render it almost unnecessary to devote a special section to the 
subject of treatment. As a general rule, it will be found that any- 
thing which improves the general health and promotes oxidation 
will diminish the tendency to deposit oxalate of lime. Cold bathing, 
exercise, attention to diet, and the mineral acids, bitter tonics, and 
iron, are usually prescribed with advantage. I feel that by many 
writers too much has been made of the indications for treatment 
afforded by many of these urinary salts. Many cases of what has 
been called the * oxalic acid diathesis,' because the urine contains 
octohedra of oxalate of lime, may in truth be treated by the prac- 
titioner just as successfully without taking into consideration the 
presence of the oxalate as by laying stress upon this fact. The 
patient will probably, in either case, be treated with tonic infu- 
sions and dilute acids (nitric or hydrochloric, or both), with a gentle 



CYSTINE. 853 

puTgative now and then. Pepsin may also be giyen. The diet 
should be simple, and small quantities of whisky or brandy in seltzer 
or Vichy water may do good. 

Although the octohedra of oxalate of lime afford no special indi- 
cation for treatment, the dumb-beUs, on the other hand, certainly do 
so ; for these dumb-bells may form the nuclei of renal calculi. In 
cases, therefore, in which they are found, it is well to promote their 
expulsion from the kidney, and endeayour to prevent the formation 
of more by giving mild diuretics, with plenty of fluid. Two or three 
glasses of Vichy water daily for two or thre^ days will generally wash 
these crystals out of the tubes and prevent the formation of others. 

411. Oystine (C^BrKSaOs) occurs occasionally as a crystalline sedi- 
ment in urine, and also enters into the composition of a rare form of 
calculus which has been termed the cystine calculus. Cystine was 
formerly spoken of under the name of cystic oxide, and the same 
term was applied to the calculus. 

Cystine forms a whitish deposit, which is found, upon micro- 
scopical examination, to consist of characteristic Hx-sided plates 
(Plate XIV., Fig. 72), which may be distinguished from uric acid 
crystals of the same form by dissolving a portion of the deposit in 
ammonia. Upon the spontaneous evaporation of this ammoniacal 
solution, the cystine is again deposited unchanged in its hexagonal 
crystals; while uric acid would have been converted into urate 
of ammonia, which, on evaporation, would have remained as an 
amorphous residue. Ammonia, it appears, merely dissolves the 
cystine, and does not enter into combination with it. Cystine is 
insoluble in boiling water, in strong acetic acid, and also in very 
weak hydrochloric acid; but it is readily dissolved by oxalic, and by 
the strong mineral acids. The most remarkable property of this 
substance is, that it contains as much as 26 per cent, of sulphur — a 
character in which it resembles taurine. Potash, like ammonia, 
readily dissolves cystine; but it is insoluble in carbonate of ammonia. 
The presence of sulphur in cystine may be proved by heating the 
substance in an alkaline solution of oxide of lead, when a black 
precipitate of sulphuret of lead occurs. This test cannot be regarded 
as characteristic of cystine, because all animal matters containing 
sulphur exhibit a similar reaction. Urine containing cystine is said 
to smell very much like sweet briar. 



854 ANALYSES OF URINE 

Dr. Oolding Bird has observed that calculi composed of this 
sabstance undergo a change of colour by long keeping. From pale 
yellow or fawn coloured, they have been found to assume a greenish 
grey, and sometimes a fine greenish blue tint. Crystals of cystine 
may be obtained from a calculus composed of this substance by 
dissolving a portion in a solution of potash, and adding excess of 
acetic acid to the alkaline solution, when the cystine will be 
deposited in six-sided plates. Virchow and Cloetta have proved 
that cystine is sometimes found in the liver; while taurine as well 
as cystine have been detected in the urine. 

Of tJie conditions of system which give rise to the elimination of 
this substance by the kidneys, little is at present known. In the 
majority of cases in which it has been found, the general health and 
nutrition of the patient have been bad. Dr. Johnson found cystine 
once in the urine of a prisoner, and it is from time to time met with 
in the urine of ill-nourished persons. 

When examining the urine of the insane for Dr. Sutherland 
{"^ Trans, Med, Chir. 8oc.,'' Vol. XXXVIII., 1855, p. 26), I was 
surprised at the number of specimens which emitted large quantities 
of sulphuretted hydrogen after standing a few days. It is not im- 
probable that the sulphur resulted from the decomposition of cystine 
or some allied substance. 

412. Anal3rsis of XTrine containinfir Cystine. — The notes of the 
following interesting case were kindly famished by Dr. Milner Barry 
of Tunbridge Wells, who also procured for me some specimens of the 
urine for analysis. 

Case. — " Mr. A., aged 23, dark complexion, well built and well 
nourished, of active habits, assiduously engaged in the duties of a 
laborious profession, sufiers occasionally from sick head-ache, but is 
otherwise in the enjoyment of excellent health. The presence of 
cystine was ascertained microscopically at the beginning of October, 
1857 ; but, as deposits supposed to be urates had often been pre- 
viously noticed, the probability is that the cystine had been excreted 
in the urine for a long time. It seems now never to be absent from 
the urine. Debilitating agencies, and whatever promotes the meta- 
morphosis of tissue, intellectual exertion, active bodily exercise, 
mental anxiety, and smoking, appear to cause an increase in the 
amount of cystine. You wDl observe the much larger relative 



CONTAININQ CYSTINE. 



355 



proportion of the ingredient in the morning urine than in that passed 
in the evening a few hours after a meal. There is no lumbar pain, 
and no irritability of the bladder." {^^ Archives of Medidne,^^ Vol I.) 
The first specimen of urine was received in October, 1857. It 
was of the natural colour, of acid reaction, and had a smell not 
unlike that of sweet briar. Specific gravity, 1028. 



Analysis 67. 



Fixed 
salts, 
1600 



Water . 

Solid Matter 
Urea 

Uric acid . 
Extractive matter 
Sulphuric acid . 
Chloride of sodium 
Earthy phosphates 
, Alkaline phosphates 



937-60 

62-40 

32-80 

•50 

12-90 

1-70 

1200 

1-00 

2-60 



In 100 grs. of 
solid matter. 



51-28 

•80 

20-67 

2-72 
19-23 

1-602 



4-00 



The next specimens were received on January 28th, 1858. No. 68 
was passed on the morning of the 27th, at eight o'clock (before 
break&,st). Its specific gravity was 1034. 



T^ 


Analysis 6i 
/"ater 


5. 

916-00 


In 100 grs. of 
solid matter. 


Solid matter. 


84-00 




Cystine . 


•906 


1-08 


Urea . . 


49-00 


58-33 


Extractives 


16-94 


19-52 




Chloride of sodium . 


9-30 


11-07 




Sulphuric acid . 


4-50 


5-35 




Earthy phosphates . 


•60 


•71 




Alkaline phosphates . 


420 


5-00 



Fixed 
salts, 
17-6* 



No. 69 was passed at 9 p.m. on the 26th, three hours after dinner. 
Specific gravity, 1027. 

* In these analyses the fixed salts were estimated by incineration, while the sul- 
phuric acid, phosphoric acid, and chloride of sodium, were estimated volnmetrically. 
The slight discrepancy in the numbers arises partly from the volatilisation of some 
of the saline constituents during incineration, and partly from slight errors in the 
analyses, unayoidable when only small quantities are operated on. 



856 



OP CYSTINE CUNICALLT. 



Analysis 69. 



Fixed 
salts, 
19-6 



In 100 grs. of 
solid matter. 
949-30 
5070 
Too little to estimate. 



Water. 

Solid matter 
Cystine . 

tJrea .... 2840 5601 

Extractives . . . 1*30 276 

'Chloride of sodium . . 11*20 22*09 

Sulphuric acid . . . 1-90 374 

Earthy phosphates . . '60 1*18 

^Alkaline phosphates . . 2*30 4*53 

In these analyses, it is interesting to notice that the sulphuric 
acid is hy no means deficient ; indeed, in the second, the amount 
present is considerably above the average quantity met with in 
healthy urine. The proportion of cystine present, although it 
occupied a considerable bulk, was really very small; so that the 
opinion commonly entertained with reference to cystine being a 
compound in which the sulphur is removed from the organism in an 
unoxidised state, in consequence of the oxidising processes being in 
a low condition, will not explain its formation in the present 
instance, as the analyses prove that a much larger quantity of 
sulphur passed off as sulphuric acid than in a state of combination 
in the form of cystine. It is interesting to notice the large pro- 
portion of sulphuric acid present when the cystine existed m 
sufficient amount to be determined quantitatively. 

413. Of Cystine Clinically, and of the Treatment of Oases 
in which Deposits occur.— Cystine has been met with in several 
different conditions of the system. In most of the recorded cases 
the patients have, however, been in a low weak state of health. 
Little is known with reference to the origin of this substance. It 
has been supposed to result from hepatic derangement, and Scherer 
and Virchow have detected cystine in the liver in disease. It is 
curious that cystine deposits occur in families, and even appear to be 
hereditary. Dr. Golding Bird speaks of an instance of its occurrence 
in three successive generations. As regards treatment I have 
nothing to add to the remarks made by Dr. Prout and Dr. Golding 
Bird. It is important to attend to the general health, and in several 
cases iron and the dilute mineral acids seem to have been of use. 



CARBONATE OF LUfE. 357 

414. Carbonate of Lime is said to occur occasionally in the 
crystalline form in human urine; its microscopical characters are 
somewhat similar to those of the carbonate of lime which is met 
with in the urine of horses and other herhivora; but the crystalline 
spherules are smaller and more delicate. From the drawings given, 
it would seem that the slender crystals of which the globular mass is 
composed are not arranged so compactly together as in the case of 
the salt so common in horses' urine. In highly alkaline urine, in 
which the alkalescence is caused by carbonate of ammonia set free 
by decomposition of urea, carbonate of lime occurs in small quantity, 
but in an amorphous form. This is the only form in which I have 
yet seen carbonate of lime in human urine. Carbonate of lime may 
be recognised by the effervescence produced upon the addition of a 
drop of acetic acid to the deposit suspected to contain it, care being 
taken that the sediment be well washed with distilled water before 
adding the acid, in order to remove any soluble carbonate that may 
be present. 

Urinary calculi containing carbonate of lime have been met with, 
but they are not common. Mr. Hitchings, of Oxford, has removed 
two or three, which are deposited in the Oxford Museum. 

Chalk or marble is occasionally added to urine, for the purpose of 
deceiving us. The presence of these substances is easily recognised 
by the action of acid, and by their being insoluble in water. 

415. Silica, or Silicic Aoid (fiiiOs)—- Sand. — It is asserted that 
silica sometimes forms a constituent of calculi. Berzelius long ago 
showed its presence in minute quantity in the ash of human urine ; 
but it has never been met with as a deposit in this secretion, unless 
placed there in the form of sand, for the purpose of imposing upon 
us. I have received the urine of a hysterical girl for examination, 
containing nearly a fourth of its bulk of conmion housenaand. In 
this quantity we could hardly fail to detect its composition; but 
the presence of a few grains might possibly give rise to some little 
difficulty, when they were found in urine. Their nature, however, 
would be determined by treating them with boiling nitric acid, in 
which they are quite insoluble. Under the microscope, they appear 
as crystalline particles of a very irregular form. 

416. Blood-corpusoles usually form a red or brownish-red gran- 



358 CLINICAL IMPORTANCE 

ular deposit, which sinks to the bottom of the vessel. A few cor- 
puscles are diflfused through the urine. If the urine be perfectly 
neutral, or slightly alkaline in its reaction, the colour of the globules 
will be bright red; while, in those instances in which the reaction 
is decidedly acid, the globules will be found of a brown colour, 
imparting to the supernatant fluid a ^^ smoky" hue. When the 
urine has a decidedly "smoky appearance,*^ it generally happens 
that the blood is derived from the kidney; while, in the majority of 
cases in which it retains its florid colour, it comes from the bladder, 
prostrate, or urethra. Although the blood comes from the kidney, 
it will exhibit its ordinary florid red colour if the urine be 
alkaline. If blood-globules remain long in urine, they become 
much altered in form, the outline appearing irregular and ragged, 
and the surface granular. JSTot unfrequently the blood-corpuscles 
appear swollen and very much enlarged. These changes, no doubt, 
are chiefly dependent upon physical causes alone. The character ojf 
blood-corpuscles are represented in Plate XXI., Fig. 3, a, 6, c, taken 
from the living body; d, e, /, from the urine ; d, corpuscles smaller 
than natural; at e, their circumference serrate and ragged; and at 
/, a somewhat similar appearance is shown. 

417. Chemical Characters of Urine containinfir Blood. — Urine 
containing blood-corpuscles must also contain serum ; but the quan- 
tity of this fluid is in many cases very small, although numerous 
blood-corpuscles are to be discovered by microscopical examination. 
If there be much blood, the albumen of the serum is readily 
detected by the ordinary reagents. 

418. Of Blood in the XTrine clinically.— Blood in the urine may 
be derived from any part of the genito-urinary mucous membrane. 
In the female, it often escapes from the vessels of the uterus or 
vagina. It is, of course, always met with in the urine of the female 
at the catamenial periods. {See Plate XXII., Fig. 117.) 

Blood may come from the kidney, in consequence of recent 
inflammation or old-standing disease leading to congestion and 
subsequent rupture of the vessels of the Malpighian body, or 
its escape may depend upon that peculiar condition of system 
in which there is a tendency to capillary haemorrhage in all parts 
of the body. 



OF BLOOD m THE URINE. 359 

When blood-corpuscles are found entangled in casts, we may 
feel certain that they come from the cortical part or secreting 
structure of the kidney. In these cases, the urine is generally acid 
and exhibits the well-known * smoky' appearance which depends 
upon the action of the acid of the urine upon the colouring matter 
of the blood. 

In cases in which, from various symptoms, we are led to suspect 
the existence of chronic kidney-disease, it is a favourable sign if tiie 
albumen is not detected after we fail, upon microscopical examin- 
ation, to find blood-corpuscles. If the albumen, however, continues 
to be passed, we may feel certain that it was not solely derived from 
the serum which escaped through the ruptured capillary vessels with 
the corpuscles, but is to be attributed to chronic renal disease. 

Haematuria may depend upon a calculus being impacted in the 
kidney, in which case it occurs perhaps for a day or two, and then 
ceases recurring after some days, or upon a calculus in the bladder. 
The existence of fungus of the kidney or bladder is almost invariably 
accompanied by haemorrhage, which is sometimes very violent and 
exhausts the patient. The escape of blood may also be due to 
disease of the bladder or prostate. 

Simple haemorrhage, not dependent upon organic disease, some- 
times takes place from the mucous membrane of the bladder, as well 
as from other mucous membranes, as that of the nose, throat, lungs, 
stomach, &c. ; but it must not be forgotten that slight haemorrhage 
is often the very first symptom of that terrible malady cancer of the 
bladder, and the practitioner should, therefore, in a doubtful case, 
always give a very guarded opinion. 

I have seen small quantities of blood passed day after day by 
a healthy man just as micturition ceased. It seemed as if the 
efibrt to expel the last drops of urine had caused the rupture of 
a few capillaries about the membranous part of the urethra or neck 
of the bladder. The haemorrhage ceased after a time without 
resorting to any special treatment. 

The possibility of haematuria depending upon the presence of ento- 
zoa in any part of the renal apparatus must also be borne in mind. 

419. Of tlie Treatment of Haematuria.— If the blood present 
in the urine has escaped from the kidney in consequence of acute 
congestion or inflammation, as may generally be determined by the 



860 TREATMENT OF HEMATURIA. 

sadden accession of the symptoms — ^the small quantity of the niine, 
the presence of casts, with a considerable quantity of albumen, the 
occurrence of some amount of puffiness about the fs^ce, and perhaps 
lumbar pain — ^the case must be treated by rest, purgation, sweating, 
and, in bad cases, the patient should be cupped over the loins («^§ 257). 

If the escape of the blood from the kidney is due to a low state 
of health, or to a condition of system allied to that which gives rise 
to purpura, the treatment must be directed to improving the general 
hMth and the action of the stomach ; tonics, the tincture of sesqui- 
chloride of iron or gallic acid, may be given ; quinine, dilute adds, 
and pepsin, also do good. If hsematuria occurs in the course of a 
case of scurvy, the scurvy, not the hsematuria, must, so to say, be 
treated ; lemon or lime juice, as generally given in this disease, will 
be of essential service. 

In cases where the hsemorrhage depends upon calculus, rest in 
the recumbent posture, warm fomentations, small doses of opium by 
the mouth, and a suppository in the rectum will often afford relief 
(see also § 464 on the treatment of renal calculi). 

Haemorrhage from the kidney is not uncommon in cases of con- 
tinued fever. Sometimes it occurs in the course of pneumonia ; and 
I have seen it in three or four cases of acute rheumatism. In all 
these conditions the vessels of the kidneys and internal oigans 
generally are highly congested. The symptom generally passes off 
after a few days, but in one case of acute rheumatism it persisted for 
three weeks, producing an anaemic condition; cupping over the 
loins and several remedies were tried, but did not seem to produce 
any immediate effect upon the haemorrhage, which gradually 
subsided. Turpentine in this as well as in many other forms of 
haemorrhage seems to do good in some cases. Acetate of lead in 
doses of three or four grains every three hours, for five or six doses, 
sometimes checks haemorrhage. This remedy was much employed 
by Dr. Golding Bird. It is of course very important not to continue 
giving lead for any length of time, and it should be borne in mind 
that some persons are more susceptible to its influence than others. 
If the blue line should appear near the free edge of the gums, the 
lead must be stopped and its elimination promoted by purgatives 
and sudorifics. 

Gallic acid is one of the most powerful remedies in haemorrhage 
from the kidneys or bladder. It may be given in much larger doses 



SPORULES LIKE BLOOD-CORPUSCLES. 361 

than usually recommended. I have given from ten grains to 
half a drachm five or six times in the twenty-four hours in many 



HsBmorrhage depending upon cancer of the kidney or hladder is 
sometimes one of the most formidable symptoms of this disease, and 
the treatment is necessarily only palliative. Gallic acid, opium, and 
complete rest sometimes afford great temporary relief. If in such a 
case the hsBmorrhage is dangerous from its excessive amount^ ice 
should he applied to the pubis, and styptics may be injected into Ihe 
bladder ; 20 to 40 grains of alum may be dissolved in a pint of water 
(Prout) and injected. I have never had occasion to resort to this 
plan. If the blood coagulates in the bladder, some trouble may be 
experienced in its removal, but gradually the clot becomes softened, 
and passes away piecemeal. The injection of water facilitates its 
expulsion. 

420. Circular Sporules closely resembling* Blood-Corpuscles. 
— Occasionally the sporules of fungi are found in urine which very 
closely resemble blood-corpuscles in size, and also in their general 
appearance. ("Archives of Mediciney"* Vol. II., p. 49.) Upon very 
carefiil examination, however, with a high power, a little eminence, 
which is the first commencement of the formation of a new sporule 
from the parent, may frequently be observed projecting from them. 
Not unfrequently two sporules may be seen together, one having 
grown from the other. Some sporules, resembling blood-corpuscles, 
are represented in Plate XXI., Fig. 113. They vary in size more 
than blood-corpuscles. A short time since, I received a specimen of 
urine from a friend which contained numerous sporules; and the 
resemblance to blood-corpuscles was so great that, had I efiStoined 
the specimen carelessly, I should certainly have considered them to 
be of this nature. By using a power of seven hundred diameters, 
their characters were distinctly made out. In these cases, albumen 
due to the existence of kidney-disease may be found in small 
quantity, which would complicate the case, and increase the chance 
of our being led to form a wrong conclusion. When doubt exists, 
the deposit should be set aside for a few days, exposed to the air in 
a warm place, when the spores will germinate, and all question as to 
their nature will be removed. 



362 CANCER-CELLS. 

Bodies babely met with in IJbinabt Deposits, and 
Substances op a doubtful Natube. 

Under this head I must include tubercle and cancer, and a few 
bodies of the nature of which I am not perfectly certain. Some of 
these substances have been carefully examined by other observers, 
but the results have not been sufficiently satisfactory to justify 
positive statements as to their nature. 

4fil Cancer-Oells. — In cases of cancer of the bladder, it is not 
uncommon to meet with well-defined cancer-cells in the urine. Some 
time since, Mr. Fergusson requested me to examine for him a small 
portion of gelatinous -looking matter, which had been passed by a 
patient suffering from bladder-affection. Of the exact nature of this 
matter there had been some difference of opinion. Upon treating a 
fragment of it with a little glycerine and water, and subjecting it 
to examination with a power of two hundred diameters, I had no 
difiiculty in making out loops of capillary vessels covered with a 
thick layer of cancer-cells. The specimen presented the usual 
appearances which distinguish a cancerous tumour which is rapidly 
growing into a hollow viscus, and was evidently one of the tongue- 
like or villous processes, broken off from the mass. There could, 
therefore, be no further doubt as to the exact nature of the case. 
The diagnosis was confirmed by subsequent examination of the parts 
after the patient's death. 

I have lately seen four cases of cancer of the bladder, in every 
one of which the disease was detected for the first time by the 
microscopical examination of the urine. In two of these cases, 
there was an abundant deposit of a dark brown colour, much 
resembling blood in appearance when it occurs in acid urine. This 
brown deposit was found to consist principally of a vast number of 
cancer " cells," varying greatly in form and size, most of them being 
very large. Many were of considerable length and contained "cells" 
in two or three different places. These so-called " cells " consist, in 
fact, of a soft material corresponding to the wall of a normal 
epithelial cell, in which masses of germinal matter are embedded in 
considerable number. A very good specimen of cancer-cells from 
the bladder is represented in Plate XXIL, Fig. 119; and in Fig. 120, 
a young cell of normal bladder epithelium is seen. It is undergoing 
division ; the cancer-cells multiply in the same way, but faster and 



TUBERCLE CORPUSCLES. 363 

irregularly, instead of succeeding each other in an orderly manner, 
layer after layer. 

From time to time, specimens of urine are sent for examination 
containing numerous well-defined spindled-shaped cells, which, from 
their general resemblance to the cells of scirrhus, are sometimes con- 
sidered to prove the existence of this terrible malady in connexion 
with the kidney or bladder. In several such instances, I have no 
doubt that the cells in question have been derived from the ureter, 
and their presence was quite unconnected with disease. (Plates IX., 
XV., XIX., Figs., 46, 76, 100 b,) It is very important to bear in 
mind that the epithelium of the ureter, and some cells derived from 
certain parts of the mucous membrane of the bladder, very closely 
resemble in form and general appearance the drawings which are 
given of the cells of hard cancer. 

422. Tubercle Corpuscles.— Tubercle is occasionally met with 
in urinary deposits. Dr. Thudichum (" TJie Pathology of the Urine,^^ 
p. 265) alludes to a remarkable and undoubted case which he saw in 
the Brompton Hospital. It is often very difficult to identify tuber- 
cular matter in sputum ; and in many cases where the deposit 
escaped in the urine, the disintegration of the tubercular matter 
would be so great as to interfere with its detection. The characters 
of tubercle are represented in " Tfie Microscope in its Application to 
Practical Medicine,'^ 2nd edition, pages 276 and 290. 

423. Of tlie Clinical Importance of Cancer and Tubercle in 
the XTrine, and of tlie Treatment of these Cases.— Unfortunately 
the very positive evidence of cancer-cells, afforded by microscopical 
examination, prevents us from giving any hope of a favourable 
termination of the case. The disease must sooner or later be fatal. 
In my experience the suffering is far less in those cases in which a 
large quantity of the cellular growth forms upon the surface of the 
mucous membrane, small masses becoming detached from time to 
time, than when the muscular coat of the bladder is the chief seat of 
disease. I have known cases of the former disease in which there 
was scarcely any suffering, the patients dying in from two to three 
years, after the cells were first found in the urine, from the gradual 
exhaustion caused by the haemorrhage which sometimes takes place 
daily and never entirely ceases. The object of treatment is simply 
palliative. Tincture of the sesquichloride of iron or gallic add will 

B 3 



364 LARGE ORGANIC GLOBULES. 

restrain the hsemorrhage if very violent. It is important to keep 
the urine in as healthy a condition as possible. If it be either very 
acid or alkaline the patient's suffering will be increased. If the 
pain or irritability of the bladder is excessive we must give opium 
by the mouth or by the rectum. 

424. Spherical Bodies containing* Nuclei and Granular Mat- 
ter. — Round structures presenting these characters are not unfre- 
quently met with in specimens of urine ; but I have not been able 
to determine with accuracy the portion of the mucous tract from 
which they are derived, or their pathological importance. 

The cells represented in Plate XXII., Fig 114, were found in the 
urine of a patient suffering from rheumatic fever, a. In the natural 
state, h. Treated with acetic acid. o. Cells resembling pus. d. The 
same treated with acetic acid. The small circular bodies are altered 
blood-corpuscles, x 215. 

The large cells above referred to contained several transparent 
bodies within them, which became very distinct upon the addition of 
acetic acid (nuclei?). The central bodies did not refract like, nor 
did they present the circular, dark, and well-defined outline, so 
characteristic of, oil-globules. 

In Fig. 115 are represented specimens of large cells filled with 
dark granular matter, but not containing any oil-particles, from the 
urine of a case of chronic bronchitis. There were also a few pus- 
globules present in this specimen. Fig. 116 represents a curious cell 
found in the urine of a case of renal dropsy of seven weeks' duration. 
Casts of medium diameter, with a few small cells containing oil, were 
also present in the same specimen of urine. Of the nature of these 
bodies I am not certain, neither have I been able to ascertain from 
what part of the genito-urinary mucous membrane they have been 
derived. Every care was taken to prevent the presence of matters 
of extraneous origin; but it is not impossible that some of the 
peculiar cells have been derived from sputum which has been altered 
by the action of the urine. 

Cells presenting somewhat similar characters have come under 
my notice in several other cases; and from that portion of the 
mucous surface of the bladder known as the trigone, I have obtained 
cells agreeing with them in general characters. It is not unrea- 
sonable, therefore, to assume that many of these peculiar cells are 
modifications of bladder-epithelium. 




GRANULAR CELLS- SARCIN^- CANCER, 
Fig. 114. 



i 



® (? 



® 



c 



§ 424 

bi£-. 1L7. 







J^i£i 









§ 418 



ig. 119. 




§ 42; 



Flate XXII. 

Fig. 115. 




© -x 




§ 424 



Fig. iia. 

§ 351 



Fi^. L2U. 




§ § 353, 421 X 700 
To Jojtft ipoifte ^^^« 



SMALL ORGANIC GLOBULES. 365 

425. Small Orgranio Globules.— Under this name, Dr. Golding 
Bird has described some little bodies smaller than the pus or mucus- 
corpuscles, with a perfectly smooth exterior, and unaffected by acetic 
acid. Dr. Bird suggests that they may be nuclei which have been 
set free from a cell by the bursting of the investing membrane. 

Plate XXIII., Fig. 126, represents the appearance of the deposit 
from the urine of a patient suffering from calculus. The small round 
bodies represented in different parts of the figure were insoluble in 
strong acetic acid, and were unaltered on the addition of ether or 
potash. Many of them contained a central dark spot. They were 
accompanied with numerous small octohedral crystals of oxalate of 
lime. From their highly refractive properties and chemical cha- 
racters just referred to, it is probable that they were composed of 
oxalate of lime. 

Dr. Balfour, of Edinburgh {^Edinburgh Medical Joumal^^ 
Vol. I., 1856, p. 617, note), has shown that altered blood-corpuscles 
correspond to Dr. Golding Bird's ' small organic globules.' After the 
crenated margins, so often seen in blood-corpuscles in urine, 
have made their appearance, the globule undergoes farther change, 
until at last it reassumes its spherical appearance, but becomes much 
smaller than before, and is not altered by hot or cold acetic acid. 
These so-called small organic globules may therefore consist of little 
spherules of oxalate of lime, altered blood-corpuscleSf or the sparules 
of fungi, I have demonstrated the last in a gi-eat number of cases ; 
and sometimes they form a " visible white deposit," such as Dr. Bird 
described. It is a pity that the name " organic globule " has been 
used at all, for certainly several widely different substances answer 
to the descriptions given of it. The so-called "large organic 
globules," or " exudation or granular corpuscles," have been shown 
to consist of an aggregation of fat globules. I have, therefore, 
thought it better, in order to avoid confusion, not to employ the term 
in this work. {See note on p. 284; also, "The Microscope in 
Medidne,^ Second Edition, p. 326.) 

Should the practioner meet with objects of the nature of which 
he is in doubt, he should at once make careful drawings, and take 
notes of the case in which they occurred. The importance of all 
microscopical observers being familiar with the appearance of all 
extraneous matters likely to be found in urine, has been dwelt upon 
in § 78, et seq. 



366 



CHAPTEE XVII. 



Urine in Disease. Of Entozoa. Hydatids — Echinococci — 
The Diphaoma Crenata of Dr, Arthur Farre — Dactylitis 
Aculeaius — Strongylus Gigas — Distoma Htjematohium — 
Other Worms passed from the Urinary Organs — Parasites 
and other Animals of accidental presence in the Urine — 
Elongated Clots of Fibrin and of Blood. 



Ektozoa. 

426. Hydatids.— Echinococci have been passed from hydatid 
cysts occupying the kidney, and have been found in the urine. The 
booklets of these creatures are very characteristic, and would be 
found in the urinary deposit. Mr. Simon refers to a case in which 
small cysts were passed entire. In these rare cases, the symptoms 
of a tumour connected with the kidney are present. At length the 
cyst bursts ; the fluid with echinococci is discharged in the urine ; 
and perhaps some fragments of the cyst also escape. These and the 
booklets of the echinococci are perfectly characteristic, and cannot 
be mistaken for anything else. An account of a recent case is 
given by Mr. Curling in the " Medical Times'' of August 15th, 1863. 
Mr. Curling gave me several of the hydatids passed by this patient. 
I could not find any echinococci or booklets, but there could not be 
the smallest doubt as to the nature of the cyst. Echinococci are 
represented in Plate XXIII., Fig. 121, and the booklets in Fig. 123. 
(Dr. Sieveking, ''Lancet;' 1853; Mr. Simon, "Lancet," 1853; ''Glas- 



DIPLOSOMA CRENATA. 867 

gow Medical Journal^^ 1856; ^^ Med, Times and Oazette^^ 1855. 
For the Characters of Echinococci, see " The Microscope in Practical 
Medicine^^ Second Edition, p. 361.) 

427. Diplosozna Orenata.->The most remarkable case on record 
in which worms were passed from the urinary bladder, is one which 
is reported by Dr. Arthur Farre, who has made some most careful 
dissections of the worm, and observations on the anatomy of the ova. 
("Archives of Medicine" Vol. I., p. 290.) This is the case recorded 
by Mr. Lawrence in Vol. II. of the " Med, Chir. Trans" in the year 
1811. It is the only one on record. Dr. Farre describes the general 
characters of the worm in the article "Worms," Library of Medicine, 
Vol. v., p. 241. Rudolphi, on insuflSicient evidence, declared that 
these worms were merely lymphatic concretions; and in consequence 
this interesting and authentic case has not yet been properly noticed 
by writers on parasites. From the recent re-investigation of the 
whole subject, there can be no doubt that Rudolphi was wrong in 
his conclusions, and that these were real sterelminthous worms. In 
his paper above referred to. Dr. Farre at once sets all doubt on the 
question at rest. He now describes the minute anatomy of the 
worm and the characters of the ova. 

The patient was a woman twenty-four years of age ; and, during 
the course of two or three months, she passed as many as from eight 
hundred to a thousand worms. The worms were of two different 
kinds. The first form, which varied from four to six inches in 
length, were passed in great number. The other kind was smaller, 
varying from half an inch to an inch in length. These worms were 
passed on one occasion only ; they lived in the urine for three days, 
and moved very briskly. They belong to the genus spiroptera, and 
Rudolphi gives to them the name of spiroptera hominis. The larger 
worms have been named by Dr. Farre, from their body being double, 
diplosoma crenata. Fig. 122, Plate XXIII., represents the general 
characters of the worm, one-half the natural size. The drawing 
represents one of the largest and most perfect specimens of the 
entozoon, half the natural size. In the centre, at the upper part of 
the figure, is the sharp twist or kink, where the body is most con- 
tracted. From this point each half gradually enlarges to a certain 
distance, but tapers again towards either extremity ; the right half 
terminating, in this specimen, in a point, the left furnished with a 



368 STRONGYLUS GIGAS. 

lateral membranous flap. This half of the body shows the ab- 
dominal groove, and double crenate border. The right half, being 
spirally twisted, exhibits successive portions of the dorsal, lateral, 
and abdominal surfaces. This twisting is observable in many speci- 
mens. Towards the extremity of this hal^ numerous fibrous cross- 
bands are shown. The minute structure of this creature is very 
peculiar, and has been accurately investigated by Dr. Farre, who has 
illustrated his remarks with numerous drawings. There can be no 
doubt that, in this unique case, two new forms of intestinal worms, 
never seen before or since, were passed from the bladder in con- 
siderable number. For the details of the case, and for the account 
of the structure of the worms, I must refer to Dr. Farre's original 
paper in my "Archives,^* 

428. Dactylitis Acnleatos. — The only case on record in which 
this parasite has been found in connexion with the urinary organs^ 
is that of a girl aged five years, who was under the care of Mr. Drake. 
Several worms were voided ; and some of them were carefully ex- 
amined by Mr. Curling, whose memoir, with drawings of the worm, 
is published in the twenty-second volume of the " Transactions " of 
the Medico-Chirui*gical Society. The female was four-fifths, and the 
male only two-fifths of an inch in length. The tegument was armed 
with spines, occurring in clusters. The worms exhibited active 
movements ; and, if left in the urine, they lived for two or three 
days. There were no symptoms in the case pointing to any derange- 
ment of the urinary organs. Tliey were first noticed in the urine 
on May 2etli, 1839, and on several occasions between this date and 
June 11th, after which no more worms were passed. These entozoa 
were, therefore, only found during a period of sixteen days, and they 
were not present each day. 

429. Strongrylns GKgras. — This parasite appears to have been 
found in the human kidney on one occasion, although Kuchenmeister 
comes to the conclusion that it has never been met with. The 
specimen is preserved in the Museum of the College of Surgeons. 
It is occasionally found in the lower animals. A few years since, I 
found three beautiful specimens of the worm, two males and one 
female, coiled up iu the kidney of a large dog. The female was 
about 15 inches in length, and rather less than half an inch in 
diameter. The skin was of a very bright blood-red colour, mottled 



DISTOMA HiEMATOBItJH. 069 

with black. The males were about nine inches long, of a reddish 
brown colour, and about a quarter of an inch in diameter. The 
kidney was reduced to a mere fibrous cyst, rather larger than the 
organ on the opposite side ; and the three entozoa were coiled up 
together, and occupied its entire cavity. The ureter was pervious 
all throughout, and over its surface, and embedded in the mucus of 
the bladder, were multitudes of ova. Ova were passed in great 
number in the urine of this dog. The kidney and the female worm 
are preserved, and still in my possession. 

480. Distozna Hsexnatobium has been found in the bladder, 
ureters, and pelvis of the kidney, as well as in the veins of the intes- 
tine, in the portal veins, small intestine, gall-bladder, &c. Griesijiger 
states that this parasite is very abundant in Egypt. The eggs of 
the worm were embedded in the mucous membrane of the bladder, 
which was much congested and ecchymosed in these situations. The 
worms themselves appear to have been found in the vessels. The 
eggs often form the nuclei of small deposits of uric acid. They have 
been found adhering to the mucous membrane of the bladder, kidneys, 
and ureter. 

431. Other Worms passed from, the TTrinaxy Orgrans. — A case 
is related by Raisin in which a worm three inches long was passed 
by a man fifty years old. Moublet alludes to the case of a boy aged 
10, who voided four worms from four to five inches long, accompanied 
by pus. Other instances are recorded, but these do not seem to be 
well authenticated. 

432. Parasites and other Animals of accidental presence in 
Urine. — Intestinal worms are sometimes passed into the vessel con- 
taining the urine, and the patient not unfrequently affirms that 
they came from the bladder. Various species of acari are frequently 
met with in urine. It need hardly be said they were not formed in 
the urinary organs. Insects and their larvse are from time to time 
found in urine. Patients will positively assert that larvae of the 
common flesh-fly have been passed through the urethra. I have on 
many occasions had specimens of the common maggot and cheese 
maggot forwarded to me, with the positive assurance they had been 
voided by the patient. The presence of the tracheae in every part 

B 5 



370 CLOTS OF FIBRIN. 

of the body proye the creature to be an insect, and it need scarcely 
be said that an air-breathing insect could not haye been developed 
in any part of the urinary organs. These insect larvse will pass 
through the entire tract of the intestinal canal in a living state. 
{See ^^The Microicape in its Application to Practiced Medicine*^ 
and papers by Dr. Brinton and Mr. Blood in Vol. III. of my 
''Archives:') 

488. Elonflrated Olots of Fibrin or of Blood are occasionally 
mistaken for intestinal worms. Microscopical examination will 
enable any one at once to distinguish them. 



371 



CHAPTER XYIII. 



Of Urinary Calculi. — General ConstderaHon of the Subject — 
Animal Matter in Calculi — 0/ the Concentric Layers — 
Of the Classes of Urinary Calctdi, and of the Chemical 
Examination of Calculi — Tests kept in Small Bottles with 
Capillary Orifices, Class I. Calculi which leave only a 
Trace of fixed Residue after Exposure to a red Heat — Uric 
Acid Calculi; Chemical Characters — Calculi composed of 
Urates ; Chemical Characters — Uric Oxide, Xanthic Oxide, 
Xanthine — Cystic Oxide or Cystine — Fibrinous Calculi — 
Fatty Concretions. Class II. Calculi which leave a con- 
siderable Quantity of Fixed Residue after Exposure to a red 
Heat — Oxalate of Lime Calculi ; Chemical Characters — 
Calculi composed of Earthy Phosphate; Chemical Characters 
— Carbonate of Lime Calculi — Silicic Add Calculi — 
Prostatic Calculi — Summary of Chemical Characters of 
Calculi — Of the Origin and Formation of Urinary Calculi, 
and of the Nature of the Nucleus"^ On the relative Frequency 
of the Occurrence of the different Calculi — On the importance 
of the administration of increased quantities of Fluids in 
certain Calculous and other affections — On the methods of 
dissolving Urinary Calculi — On dissolving Calculi by 
Electrolysis — Lithotomy and Lithotrity, 

434. General Considerations on the Formation of Oalonli. — 
As there are several substances in healthy urine possessing but a 
slight degree of solubility, which, in certain derangements of the 
physiological actions of the body, are produced in much larger 
proportion than in health, while other matters not present in 
healthy urine, and not readily soluble in water, are sometimes 



372 ANIMAL MATTER IN 

formed, it is not to be wondered at that from time to time some of 
these matters are slowly deposited in the insoluble form from the 
urine while it yet remains in the bladder, or even before it reaches 
this organ. It is very interesting to consider the nature of the 
various conditions which are likely to lead to this deposition of inso- 
luble calculous matter, and it is instructive to study the condition of 
the system in relation to the particular form of insoluble matter that 
may be deposited. If we were accurately acquainted with the mode 
of deposition of calculous matter, it is very possible that we might 
lay down such rules for the guidance of patients in whom this ten- 
dency existed as would prevent the formation of the stone, or retard 
its increase if already formed. The deposition of a calculus does 
not always depend upon the state of the urine ; for it is possible 
that the urine may be healthy while a stone is forming, and that the 
changes taking place on the surfsice of the stone itself may cause the 
precipitation of insoluble substances. Remedies which act on the 
kidney in many cases exert no influence upon the formation of a 
stone. It is very important in connexion with this subject to study 
the general chemistry of the body carefully ; for it will often be 
found that the tendency to calculus disorder is explained by deranged 
chemical changes, which may perhaps be materially modified by 
attending to the action of the alimentary canal and skin, altering 
the mode of living, and administering the salts of the vegetable acids, 
alkalies, mineral acids, or mere diluents in large quantity, according 
to the nature of the case. 

In those cases in which the deposition of the calculous matter 
mainly depends upon the urine being in a state unfavourable for 
holding certain slightly soluble matters in solution, it follows that 
the tendency to deposit may be averted, if the condition of the urine 
can be altered. It is possible that at one time an acid state of urine 
may favour the precipitation of uric acid; while, after a short interval, 
its characters may become so altered that it becomes alkaline. Not 
only does the precipitation of uric acid cease, but phosphates, which 
are insoluble in an alkali are deposited. Fhosphatic salts are soon 
deposited on the uric acid, and it is by them effectually protected 
from the further solvent action of an alkali. 

435. AniTnal Matter in Calculi.— Calculi often consist of many 
different constituents; but usually one predominates greatly over 



URINARY CALCULI. 373 

the rest, and the calculus is named accordingly. Even the purest 
calculi composed of earthy salts contain, nevertheless, a certain 
quantity of organic matter; and those which seem to consist of 
organic material only, contain a certain proportion of earthy salts. 
A certain amount of animal matter is deposited with the hard 
material, and in many cases serves to agglutinate the particles 
together. The precipitation of any saline matter in a viscid substance 
like gum or mucous will be deposited in the form of a spherical 
mass instead of in its usual crystalline form. {See Mr. Rainey's 
" Observations on the Formation of Shell, rfc") After the hard 
matter of a stone has been dissolved, this animal matter may be seen 
in the form of a translucent, granular, mucus-like mass. Upon 
microscopical examination, sometimes the remains of delicate fungi 
can be detected in this matrix, and very frequently dumb-bells of 
oxalate of lime, or firagments of them, are found. The fungi were 
formed during the formation of the calculus; and it is probable that 
the reaction developed in the fluid in contact with them during their 
growth caused the continued precipitation of the insoluble matter. 

The hard calculous matter may consist of substances which exist 
in healthy urine, like phosphcttes and uric acid, slowly deposited 
from their weak solution in the secretion; or of materials which are 
not present in perfectly normal urine, such as oxalate of lime, 
cystine, (S^c. 

436. Of the Ooncentric Layers of Oalonli. — The insoluble 
material is deposited in distinct layers, which can often be readily 
detached and separately examined. These layers are easily demon- 
strated by making a section of the calculus, which can, except in 
the case of the hardest and most brittle calculi, be readily effected 
as follows. The calculus is to be sawn through with a fine sharp 
saw. The cut surface is next to be ground smooth, by being rubbed 
down upon a smooth flat hone with water. When it is perfectly 
even, it may be washed and allowed to dry. Lastly, the cut surface 
is to be varnished; and now all the different layers will be seen most 
distinctly. If the calculus be very brittle and hard, unless it be 
sawn through with a diamond wheel, it is better to grind away one- 
half without attempting to saw through it. Small calculi are very 
easily ground and polished, and often furnish very instructive 
specimens. 



374 CHEMICAL EXAMINATION 

The concentric layers are often of different colours, of different 
degrees of hardness, contain various proportions of organic ba^, and 
are of different chemical composition. Each ring forms the section 
of a layer, and a portion of each may be detached and chemically 
examined separately. Some of these layers are deposited quickly, 
others more slowly; and they therefore vary considerably in haidnesa 
In examining a calculus, it will be necessary to subject a small 
portion of several layers separately to examination. 

Concentric layers may be demonstrated in the most minute 
calculi, even in those microscopic calculi which require to be 
examined under a power of 250 diameters. {Ses ^^lUiutrationSy^ 
Calculi, Plate I., Figs. 1, 2, 3, 4.) 

Seldom can any definite crystalline form be made out, except 
upon the surface of the concretion; and upon examining small 
portions of a calculus in the microscope, nothing but a great number 
of crystalline fragments, exhibiting concentric layers, can usually be 
distinguished. Sometimes the material is at first deposited in 
separate little spherical masses, which become aggregated and at 
length become incorporated together. Although distinct names are 
assigned to different forms of calculi, a concretion entirely composed 
of only one substance is seldom met with. 

Op the Classes op Urinary Calculi, and op the Chemical 
Examination op Calculi. 

For convenience of description, calculi may be arranged in two 
classes, according to the relative proportion of the organic matter 
and inorganic salts present. The combustible, or almost entirely 
combitstible calculi, are those which leave very little residue after 
exposure to the action of a red heat on platinum foil ; while the 
partially combustible or incombustible calculi leave a considerable 
proportion of fixed residue. 

487. I. The first clajss will include calculi composed of uric 
acid, urates of amm/)nia, soda, lime, and m>agnesia, and the rare 
forms of uric or xanthic oxide calculi, fibrinous and bhod calculi, and 
those consisting of cystine, 

488. H. The second class will contain the oxalate of lime or 
mulberry calculus; the calculi composed of various phosphatic 



OP URINARY CALCULI. 375 

deposits; that consisting of carbonate of lime, very rare in the 
human subject, but not uncommon among the lower animals ; and 
the sUioio acid calculus. 

The first preliminary test to which a portion of calculous matter 
of unknown composition is subjected, consists in exposing it to the 
action of a red heat. When reduced to a fine powder, a little is 
placed upon a piece of platinum foil, and heated in the flame of a 
spirit-lamp. If a carbonaceous mass remain, it is to be exposed for 
some time to a red heat, until it is entirely dissipated, or until 
nothing but a white ash remains. 

If it be almost entirely dissipated, the original powder is to be 
tested for uric acid, urates of soda, lime, ammonia, or cystine, 
according to the method described for testing for these substances 
occurring in the form of urinary deposits. 

If the powder be incombustible, or only partially combustible, it is 
to be tested for phosphate of lim£, triple phosphate, and oxalate of 
lime, by the methods indicated. (See Table VI.) 

439. Tests kept in Small Bottles with Capillary Orifices. — 
In Chapter 1. 1 have directed attention to a very convenient plan 
of keeping reagents, which is not only applicable to the subject 
now under consideration, but will be found of great advantage in all 
cases in which only a very small portion of matter is to be subjected 
to examination, particularly in ascertaining the chemical characters 
of substances which form the subject of microscopical inquiry. The 
plan of examining the chemical composition of a substance which I 
am about to describe may be termed not inaptly microscopical testing, 
A chemist may carry his laboratory in his pocket ; and the physician 
may take all the apparatus necessary for the most complete quali- 
tative examination he is ever called upon to make, in a space much 
less than that now usually occupied by the urinometer, spirit-lamp, 
and acid-bottles. 

These little test-bottles have been arranged in a case, with the 
urinometer and other apparatus required for the examination of 
urine. The mode of filling these test-bottles is described in § 34, 
p. 8. When we proceed to test a small portion of calculous matter, 
it is to be powdered, and placed on a glass slide. The cap is 
removed from the test-bottle containing the appropriate reagent, 
which is then inverted, and its capillary extremity placed near to 



376 URIC ACID CALCULI. 

the matter or drop of solution to be tested. The warmth of the hand 
expands the air contained in the bottle, and a drop of the liquid is 
expelled. In this way, a drop of an unknown solution can be readily 
subjected to the action of several tests, and indications of the 
presence of certain substances may be obtained as clearly as if much 
larger quantities were operated on. 

440. Teatixiflr for Carbonates.— In testing for carbonates, the 
powder or solution may be lightly covered with a piece of thin glass, 
and the acid subsequently added; the slighest effervescence becomes 
at once clearly perceptible; and, if necessary, the specimen may be 
subjected to microscopical examination, and thus the smallest 
disengagement of air-bubbles can be detected. 



Class I. — Calculi which leave only a trace of fixed residue after 
exposure to a red heat. 

441. TJrio Acid CalcnU.— Nearly two-thirds of the calculi in the 
museums of this country consist in great part of uric acid. They 
vary very much in size. Small uric acid calculi are sometimes 
formed in great number in the kidney. For the most part, the 
deposition of the uric acid commences in the kidney itself; and not 
unfrequently the small concretion becomes impacted in the lower 
part of the uriniferous tubes or infundibula, and gives rise to great 
irritation, until it becomes released, and passes down the ureter into 
the bladder. It may now pass off by the urethra ; or may remain in 
the bladder, when layer after layer is added, until it attains a 
considerable size. 

The uric acid calculus is usually of an oval form, but somewhat 
flattened on two of its surfaces. A large uric acid calculus consisting 
of concentric layers of uric acid, deposited upon a smaller calculus 
composed of oxalate of lime, is represented in Plate XXIV., Fig. 127. 
It is sometimes quite smooth externally, sometimes rough, or covered 
with a number of rounded projections. It is generally of a brownish 
hue, varying from a pale fawn colour to a dark brownish red. Dr. 
Rees met with one specimen in which the nucleus was quite white, 
and was composed of pure uric acid destitute of colouring matter. 
The consistence of the uric acid calculus is usually hard, and its 
texture compact, but rarely it is soft, and can be broken down 



CALCULI COMPOSED OF URATES. 377 

between the finger and thumb. It breaks up into small angular 
pieces. 

I have examined many small uric acid calculi, and in several 
instances have found that the nucleus consisted of matter insoluble 
in potash, which polarised readily; and, in some specimens, well 
defined dumb-bell crystals of oxalate of lime were discovered. In 
some few cases, the nucleus probably consisted originally of mucus 
or some soft matter, which after a time had shrunk and nearly dried 
up, leaving a space or cavity in the centre of the calculus; but, even 
in these, matter insoluble in potash and acetic acid exists. Very 
generally, dumb-bells of oxalate of lime form the nucleus of uric acid 
calculi. 

The uric acid calculus is often coated with phosphates. The 
irritation of the calculus, according to Dr. G. 0. Rees, excites the 
secretion of an abnormal quantity of alkaline fluid from the mucous 
membrane of the bladder, which causes the earthy phosphates to be 
precipitated from their solution in the urine. If ammonia were set 
free by the decomposition of the urine, it is possible that a little of 
the uric acid calculus might even be dissolved ; but this would soon 
be prevented by the deposition of earthy phosphate upon the surface. 
The phosphates are not secreted in increased quantity by the mucous 
membrane of the bladder, as was formerly believed, but are merely 
precipitated from their solution in the urine. 

442. Chemical Characters. — Insoluble in boiling water, soluble 
in potash. From the alkaline solution, crystals of uric acid may 
be obtained by adding excess of acid. The murexide test may be 
applied. (See Uric Acid, § 398.) When heated on platinum foil, it 
evolves an odour of burnt horn. Carbonate of ammonia and hydro- 
cyanic acid are among the products of decomposition. The small 
amount of residue which remains after the ash has been exposed to 
a red heat for some time, consists principally of phosphates and 
carbonates of soda and lime. 

443. Calculi composed of Urates.— These calculi usually contain 
urates of soda, ammonia, and lime ; and very commonly small quan- 
tities of oxalate of lime are deposited with the urates. This calculus 
is in great part soluble in boiling water, and gives off ammonia 
when heated with a strong solution of bicarbonate of potash. Dr. 
Prout states that it is principally met with in children, and is 



378 CYSTIC OXIDE. 

usually small in size, of a pale brown colour. Layers of urate are 
often found in uric acid calculi. 

444. Chemical Examination.— After treating the calculus witli 
boiling water, the insoluble matter is to be separated by filtration. 
This may consist of oxalate of lime and phosphates. If only a little 
boiling water has been added, the urate will be deposited as the 
solution cools. The solution is to be tested as follows. Acetic acid 
will precipitate the uric acid. The mixture is to be filtered, and 
the filtered solution evaporated to dryness. The. residue is to be 
exposed to a red heat. Carbonate of soda and carbonate of lime 
remain. The last may be obtained by solution in acetic acid and 
precipitation as oxalate. 

445. TJrlo Oxide, Xanthlo Oxide, Xanthine.— These names 
have been given to a rare form of calculus, which has only been 
found in man on three occasions. It is not soluble in water ; it is 
hard, of a yellowish brown colour, and the surface can be polished 
by firiction. Scherer has found xanthine in the liver and spleen, in 
muscle, and in blood. It is closely allied to uric acid, and also to 
hypoxanthine, which only differs from it in containing two atoms 
more of oxygen. {See § 401.) 

446. Cystic Oxide, Cystine.— This form of calculus is of a pale 
greenish colour ; its surface is smooth, and there are no indications 
of concentric layers. The fracture is glistening, and the structure 
is semitransparent. 

The chemical characters of this calculus are the same as those of 
cystine. {See § 411.) 

447. Flbrinotis Calciilus.— This form was first noticed by Dr. 
Marcet, and it appears to consist entirely of an elastic organic 
substance closely allied to fibrine. It is said to resemble yellow 
wax in its appearance. It dissolved in potash, but was precipitated 
by excess of acid. It was insoluble in water, alcohol, and ether; 
but was dissolved by acetic acid, with the aid of heat. In this 
solution, ferrocyanide of potassium produced a precipitate. It left 
very little fixed residue after exposure to a red heat. 

448. Blood-Calculi.— Dr. Scott Alison furnishes the following 
interesting remarks with reference to a case in which he discovered 



BLOOD CALCULI. 379 

some blood-calculi in the kidney. {^^ Archives of Medicine,^ Vol. I., 
p. 245.) Upon examining the body of a man named William Solly, 
who was admitted into the Consumption Hospital, Brompton, under 
the care of Dr. Cursham, on August 23rd, and who died on the 30th 
of the same month, the left kidney was found by Dr. Alison to be 
greatly wasted and changed in structure. The infundibula and 
pelvis were stuffed with hard bodies, most of which were of a coal- 
black colour. "The black calculi occupied the pelvis, while the 
infundibula were tenanted with a few calculi of a whitish-grey 
colour, with one exception small in size, about the magnitude of 
pear-seeds, and wanting the ordinary physical characters of phos- 
phate of lime. One calculus, which occupied an infundibulum, is 
the size of a horse-bean, looks somewhat worn and disintegrated, 
and at one point resembles a piece of decayed wood. At one side 
it is black, from the presence of altered blood. It is very light in 
weight, and is composed of blood and phosphate of lime. The black 
calculi, which form the chief point of interest in the case, were 
about six in number, and ranged from the size of a coriander-seed 
to that of a small horse-bean. When found, these black calculi were 
tolerably hard; but, being friable, they partly broke asunder in 
handling. The fractured surface varied a little in colour, in some 
parts presenting a dark rusty tint." Liquor ammonisB dissolved 
them; they were capable of partial combustion. The microscope 
revealed only amorphous particles; but Dr. Owen E^es, with the 
assistance of a neutral saline solution, discovered forms which he 
considered to be the remains of blood-corpuscles. 

The kidney was remarkably altered. It was very small, but 
retained somewhat of the normal shape. It weighed only an ounce 
and a half, and was only two inches in length. Its colour was drab; 
its consistence was firm and fibrous. At one extremity only could 
any natural cortical or tubular structure be found. The organ 
resembled a sac with thin irregular walls. The lining membrane 
appeared healthy. The renal artery was small, thickened, and 
scarcely admitted a common probe. The ureter was small, but less 
out of proportion than the artery. The investing membrane could 
not be separated from the other parts with which it was connected. 

" The atrophy of the kidney in this case was probably brought 
about by the production of inflammatory action, set up, perhaps, by 
the presence of small calculi of phosphate of lime. Blood was pro- 



380 OXALATE OF LIME. 

probably effused in consequence, and, from suppression of urine, 
remained in the infundibula and pelvis, and failed to be washed 
down the ureter. This blood hardening would form the calculi 
which were discovered. After the abatement of the supposed 
inflammatory action, degenerative processes would supervene, and 
lead to the remarkable atrophy and change which the kidney pre- 
sented. The duties of this altered kidney would be thrown upon 
the other; but, as the. system was much wasted by disease, no 
increase of size would result 

" Only a very imperfect history of the patient could be obtained, 
he being very exhausted when he came into hospital. Since his 
death, inquiries have been made for information, but with little 
success. He was fifty-two years old, and by trade a painter. He 
had been ill with cough two years, and his feet and legs became 
oedematous only two weeks previous to his decease. No information 
could be obtained respecting his having suffered from calculi in the 
bladder, or from hsematuria; but it is right to mention that no 
member of the family of the deceased could be found." 

449. Patty OonoretionB. — These have been already alluded to 
under Urostealith (§ 340). Specimens of urine which contain large 
lumps of hard fatty matter will sometimes be brought for exami- 
nation. Quite lately I have seen two such specimens, which were 
said to be cases in which concrete fatty matter had been passed in 
the urine. In these, however, the fat was ordinary suet, as was 
proved by the presence of the fat-vesicle, white and yellow fibrous 
tissue-, and fragments of vessels. 

Class II. — Calculi which leave a considerable quantity of fixed 
residue after exposure to a red heat, 

450. Oxalate of Lime Oalculi. — I have seen an oxalate of lime 
calculus not larger than the l-500th of an inch, and have traced the 
formation of these stones through their several stages. I believe 
that the dumb-bell crystals formed in the kidney, in the first place 
become aggregated together, forming small collections, as represented 
in Plate XXIII., Fig, 125; crystalline matter is then deposited in 
the interstices, and gradually a microscopic calculus results. A beau- 
tiful specimen of a microscopic oxalate of lime calculus is represented 



ENTOZO A .—DUMB - BELLS . 



Plate XXIII. 



jf\g. 121. 



i'vvi 



P?*^ 






Fig. 122. 




Fig. 123. 



§ 426 



§ 427 



§ 426 



Fig. 124. 




Fig. 125. 




Fig. 125. 



':M\:( 



^■9 



8> 



§ 405 



§ 42i 



To Jace vKVfl^'JA^- 



m 



9 



MULBERRY CALCULI. 881 

in Fig. 124. At a, a much smaller microscopic calculus is seen, 
consisting of only two dumb-bells. 

These minute calculi remain probably for some time in the 
kidney, and slowly increase until they form the concretions known 
as the hempseed calculi. Not unfrequently a number of them are 
found in the kidney, and pass down the ureter one after the other at 
various intervals of time. Sometimes one becomes impacted, and 
gives rise to the most serious and distressing symptoms. Having 
arrived at the bladder, the slow deposition of the oxalate may con- 
tinue, or layers of uric acid or phosphate may be deposited, according 
to the state of the urine. 

In cases where the oxalate increases, the surface becomes tuber- 
culated, in consequence of the irregular deposition of the salt ; the 
colour varies from a pale brown to a dark brown purple. They are 
commonly called the mulberry caJculL Such stones often attain a 
large size. They are very heavy and hard. On section, the laminsB 
are well seen, and it is often noticed that the calculous matter has 
been deposited most unequally. 

Occasionally the oxalate of lime is deposited almost colourless 
and crystalline. Dr. Prout figures one of these caljsuli. I have a 
beautiful specimen, which was given me by Dr. Gibb, and was 
obtained from the horse. Large octohedraJ crystals of oxalate of 
lime can be seen all over the surface. The small hempseed calculi, 
which are white on the surface, also exhibit numerous beautiful 
crystals, although they are smaller than those referred to in the 
last specimen. 

A beautiful example of another form of oxalate of lime calculus, 
the surface of which is of a pale brown colour, and the tubercles 
small and delicate compared with the mulberry calculus, is repre- 
sented in Fig. 131, Plate XXIV. 

Occasionally, however, in post-mortem examinations, we are 
somewhat surprised to find these calculi in the kidney, although the 
patient never suffered from the slightest symptom during life. I 
have a calculus the size of an almond, which I found fixed very 
firmly in one of the ureters of a man who died of another malady. 
Although its surface is rough, and it is half-an-inch in diameter, it 
caused scarcely any uneasiness, and there was no suspicion of its 
existence before the patient died. 

The large mulberry calculus represented in Fig. 128 was removed 



382 MULBERRT CALCULI. 

from a man aged 45, by Mr. James H. Ceely, of Aylesbury. The 
drawing is from a photograph, and represents the calculus two- 
thirds of its real size. Mr. McCormick sent me the following 
history of the case. It is not a little remarkable that a rough 
calculus like this, weighing twelve drachms, should haye been 
present without causing great pain and uneasiness : — 

"At the age of 16 years the patient (now 46) suffered from pain 
in the hypogastric region, extending along the urethra to the glans 
penis. At intervals during the succeeding twelve months the pain 
was very violent, and was at each attack followed by the evacuation 
of bloody urine. Occasionally since then he experienced pain in 
these situations, while taking horse exercise, or during unusual 
exertion, but never to any great extent, and he was never compelled 
to seek advice. 

"With these exceptions his general health, although delicate, 
had been good till last June (1868), when he had an accession of 
symptoms resembling those mentioned, but greatly aggravated. The 
urine, in addition to blood, contained * gravel.' At this time he 
consulted Mr. Reynolds, of Thame, who detected a vesical calculus, 
and on the 20th. September, Mr. J. H. Ceely, performed the lateral 
operation and removed a rough, irregular, mulberry calculus, weigh- 
ing twelve drachms. 

"During the first ten days subsequent to the operation, the 
urine contained considerable quantities of pus and blood, after 
which time all abnormal characters disappeared, and the patient 
was discharged from the Bucks Infirmary perfectly well on the 8th 
of October, and had suffered little pain or inconvenience. This 
patient had enjoyed excellent general health during a period of 
twenty-nine years, notwithstanding the presence of a calculus 
probably during the whole period." 

Another mulberry calculus, which was of a beautiful plum colour, 
is represented in Plate XXIV., Fig. 29. 

A calculus of very curious shape, the nucleus of which consisted 
of oxalate of lime, is described by Mr. Price in the eleventh volume 
of the ^^ Transactions^^ of the Pathological Society. Mr. Price 
removed fourteen calculi from the bladder of an old man by the 
lateral operation of lithotomy. Two of the calculi were peculiar in 
possessing several spine-like projections. The largest of these was 
about the size of a chestnut, and from its sur&ce projected from eight 



CHEMICAL CHARACTERS. 383 

to ten spines, two of which were upwards of half-an-inch in length. 
Surrounding the oxalate of lime nucleus were several layers of uric 
acid and urates, with some earthy phosphate. The spines were 
formed of the latter salts alone, and there was no projection of the 
oxalate of lime nucleus into them. 

The cause of their peculiar shape could not be ascertained. The 
stone was not in any pouch in the bladder, but was free in its cavity, 
and the absence of any spines projecting from the nucleus militates 
against the idea of the peculiar form having been given to it while 
in the kidney. No post-mortem was allowed. It seems possible 
that the formation of the spines might have depended upon the 
more rapid deposition of calculous matter on those parts opposite to 
the intervals between the smaller calculi, than over the part of the 
surfEU^ in immediate contact with them. Only the two largest 
calculi exhibited this peculiarity. 

461. Oliemical Cliaracters. — The powdered calculus is soluble 
in the mineral acids, and the oxalate of lime is precipitated as a 
white powder by ammonia. Acetic acid will not dissolve oxalate of 
lime. After the powder has been exposed on platinum foil to a dull 
red heat for some time, a white ash consisting of carbonate of lime 
remains. This gives oflf bubbles of carbonic acid when it is treated 
with an acid. If the temperature be much higher than a dull red 
heat, a certain quantity of the carbonate of lime undergoes conversion 
into quick lime, which does not effervesce on the addition of an 
acid. 

452. Calctdi in Patients who have had Cholera. — The cir- 
cumstances under which oxalate of lime is deposited in the form of 
the dumb-bell crystals have been already alluded to. It is interesting 
to find that both Dr. Prout and Kletzinsky have noticed deposits of 
oxalate of lime in patients who had had cholera, in which disease the 
fluids are in a high state of concentration. In two cases of this 
disease dumb-bells of oxalate of lime were found in the urine by 
myself. Dr. Prout also alludes to the frequency of cases of calculous 
disease in those who had suffered from cholera. These are important 
fects in favour of the view I entertain with reference to the 
formation of the nucleus of the calculus, which I have, in fact, 
shown to be in many cases a microscopic calculus. The concen- 
tration of the the fluids which occurs in cholera and other cases is 



384 CALCULI OF PHOSPHATE OF LIME. 

favourable to the depoation of the least soluble substances in a solid 
form. The intermediate stages between dumb-bells and small 
calculi have been actually observed, as I already mentioned. 

453. Passage of Oxalate of Lime Calotdi from the E^idney. — 
Oxalate of lime calculi often give rise to extreme pain when im- 
pacted in the kidney, and while passing down the ureter, or lodged 
in the bladder. In the kidney the pain is often of the most violent 
character, and frequently the patient suffers from many attacks 
before the stone is dislodged. Very frequently haemorrhage occurs, 
and sometimes inflammation is excited, which terminates in the 
suppuration of the tissues contiguous to the stone. 

On the other hand in many instances they pass without giving 
rise to the least inconvenience; indeed, I have known cases where a 
calculus has passed down the ureter without the patient even being 
conscious of it. 

454. Calculi composed of Earthy Phosphate. — Both phos- 
phate of lime and ammoniaco-magnesian phosphate enter into the 
composition of calculi. Dr. Prout showed that the phosphates were 
very often deposited upon other calculi, while there were very few 
instances in which uric acid, urates, or oxalate of lime, were 
deposited upon the phosphate. These two earthy salts enter into 
the composition of the fusible calculus; its degree of fusibility 
varying according to the proportion of triple phosphate present. 
The latter substance is easily fused in the blowpipe flame, while the 
phosphate of lime is quite infusible. 

When the calculus contains but a mere trace of triple phosphate 
its structure is dense and even, it is heavy, and its surface is smooth 
and polished; but large calculi of this kind are exceedingly rare. 
A small quantity of triple phosphate is almost always present in the 
large calculi. Portions of the laminsB of these calculi are easily 
broken off. 

Phosphatic calculi are represented in Figs. 130, 132, Plate 
XXIV. In both specimens the composition of the nucleus is 
different to that of the body of the calculus. In Fig. 132 a small 
uric acid calculus, with some oxalate of lime, is seen in the centre 
of the phosphatic mass. 

Phosphate of lime calculi are often found in the kidney. In 
some cases the whole of the pelvis is occupied with calculi, varying 



CALCUT.I. 



Plate XXIV. 



Fig. 127, 




Fig. 123. 



Fig. m. 



§ 450 




§ 460 



Fig. 130. 




§ 4^)4 



Fig. 131. 




§ 4:)U 



Fi6. 132. 



Fig. 133. 




§ 454 












ft 

§ 45« 



To Jace'tkOjQt'iiiiV, 



CHEMICAL CHARACTERS. 385 

in size and shape, mixed with a considerable quantity of pulverulent 
matter like fine sand. Each particle of this is found, upon micro- 
scopical examination, to consist of a minute calculus, containing a 
certain quantity of organic matter, probably mucus and disintegrated 
epithelium, for its nucleus. Several of these calculi are represented 
in the " Illustrations^'' Calculi I., Fig. 1. 

Occasionally a phosphatic calculus, lodged in the pelvis of the 
kidney, gradually increases until a large calculous mass is formed by 
the deposition of earthy salts, layer after layer, until the whole 
pelvis of the kidney is occupied with it, and its prolongations 
extend into the infundibula and calyces. 

The calculus, which consists almost entirely of triple phosphate, 
has a very porous structure; it is light, easily broken down by 
pressure, and perfectly white. Its surface is rough, and large 
crystals of triple phosphate can often be discerned upon the surface 
with an ordinary lens. 

In the deposition of phosphatic calculi, the alkali which causes 
the precipitation of the phosphates is secreted, according to Dr. 
G. 0. Rees, by the mucous membrane of the bladder. The earthy 
salts are precipitated from the urine, not secreted from the mucous 
membrane, as was formerly supposed. 

Mr. Charles Hawkins sent me several small calculi which had 
been passed by a patient, to the very large number of 600, in a 
fortnight or three weeks. They were all about the size of a small 
pea. The surface exhibited several flattened sides, evidently caused 
by so many being formed together. They looked very like small 
biliary calculi which had been packed together in the gall bladder. 
The matter of which they were composed consisted of phosphate of 
lime and ammoniaco-magnesian phosphate, with a considerable 
quantity of organic matter. Although these calculi were, in many 
respects, like prostatic calculi, it is almost certain that they came 
from the pelvis of one kidney. 

456. Chemical Gharacters. — The phosphate of lime calculus is 
infusible. It contains, like other calculi, a little animal matter, but 
this is often so small that laminae, which have been exposed to a red 
heat, retain their general characters after ignition. It is soluble in 
the mineral acids, and slowly in acetic acid. Phosphate of lime is 
precipitated in an amorphous form when the acid solution is neu- 



386 CABBONATE OF UHE CALCULI. 

tralised with ammonia. When oxalate of ammonia is added to the 
acetic add solution, a precipitate of oxalate of lime is formed. 

The calculus composed of triple phosphate and phosphate of lime 
is fusible. The solution in acids, when neutralised by ammonia, 
gives a precipitate of ammoniaco-magnesian phosphate in stellate 
crystals, and a little phosphate of lime in an amorphous form. The 
quantity of phosphate of lime present is sometimes so small, that the 
solution in acetic acid does not give a precipitate when oxalate of 
ammonia is added. Calculi, composed of triple phosphate, generally 
contain more mucus and organic matter than the other phosphatic 
calculi. 

456. Carbonate of Lime Calculi, though common among her- 
bivorous animals, have rarely been met with in man. They are 
friable, and sometimes perfectly white. Mr. Smith has described 
some which are very like the mulberry calculi {^^ Med,-Ckir. Tram,^ 
Vol. IX., p. 14). There are specimens of this form in the Oxford 
Museum, among Mr. Hitching's collection, but, unfortunately, no 
history is attached to them. Dr. Thudichum states that he has 
examined prostatic concretions which consisted almost entirely of 
carbonate of lime. A small quantity of carbonate of lime is usually 
deposited with the earthy phosphates. 

This calculus effervesces freely when exposed to the action of acids 
previous to incineration; white oxalate of lime yields carbonate only 
after having been exposed to a red heat. 

457. Silicic Acid CalculL— I have never met with calculi which 
contained silica; but Berzelius, Vauquelin, and Fourcroy, and Mr. 
Venables and others, have detected it. It exists usually in very 
small quantity only, and in order to obtain it a considerable quantity 
of the calculus must be operated upon. 

458. Prostatic Calculi. — These calculi vary very much in size. 
The small ones are roundish, but often the sides are more or less 
flattened when many have been lying in apposition. Small prostatic 
calculi are represented in Plate XXIV., Fig. 133. They are 
generally hard and white, like porcelain or alabaster, but occasionally 
have a soft porous structure. The surface is generally perfectly 
smooth. They consist of organic material, with phosphate of lime 
and a trace of carbonate ; but it is seldom that triple phosphate is 



PROSTATIC CALCULI. 387 

to be detected. The earthy matter may vary from 50 to 90 
per cent. 

These calculi are formed in the follicles of the prostrate gland, 
and commence as minute very transparent concretions, which contain 
scarcely any hard calcareous material, and at this early period of 
their formation, therefore, are not entitled to the name of calculi. 
The microscopic concretions have been detected in the follicles 
during the periods of youth and early manhood by Mr. Thompson, 
who states that he found them in every one of a series of fifty 
prostates which he subjected to examination. In old age, as is well 
known, they are often found of considerable size. When small, they 
do not give rise to any symptoms, but they may increase in size and 
number, and cause the greatest inconvenience and distress. 

In sections of the prostate which I have made from a man of 
about forty years of age, who died from pneumonia, the various stages 
of growth of these concretions can be observed. The specimen has 
been preserved in glycerine, in order to increase its transparency. 
Each follicle of the gland is seen to be occupied with many small 
roundish bodies, and a considerable number of epithelial particles. 
Many of the follicles are distended by a number of transparent 
microscopic concretions, varying from a pale yellow colour to a dark 
reddish brown. Some of the smallest are not more than the one 
two-thousandth of an inch in diameter, and yet these are seen to be 
composed of several concentric layers. In the centre of almost all 
the concretions no one can fail to notice a quantity of minute 
globules, and in some, one, or more, roundish cells may be seen most 
distinctly. These, in fact, constitute the " nucleus" of the concretion. 
The concretions under consideration consist in fact almost entirely of 
organic matter, which resists the action of moderately strong solution 
of potash and acetic acid. It is an albuminous material, which, in 
its chemical characters, agrees with the substance of which the cell 
wall is composed. The walls of hydatid cysts, and some of the 
elastic albuminoid concretions occasionally found in the peritoneal 
cavity, and in other situations, are composed of a substance closely 
allied to this. These bodies, I believe are formed by the slow 
deposition of albuminous matter round a nucleus consisting of 
epithelial cells or debris. The material which is deposited in suc- 
cessive layers has probably been formed by the cells of the gland, and 
is of nearly the same composition as the matter of which the outer 

s 3 



888 PROSTATIC CALCULI. 

part of the cells themselves consists. It is sometimes colourless, bnt 
more commonly of a yellowish colour, and sometimes reddish. A 
small concretion having been once formed, new matter is deposited 
upon it, and gradually becomes hardened by the absorption of its 
fluid constituents. 

Up to this period of its formation there is very little earthy 
matter in the concretion, but gradually a change takes place, and 
granules of phosphate of lime are precipitated in the substance of 
the transparent organic matter. This change having commenced, 
the further separation of calcareous matter goes on. The particles 
already formed increase by attracting more phosphate from the sur- 
rounding fluid, which holds it in solution. As the concretion 
enlarges, the proportion of phosphatic salts to the organic matter 
becomes greater, and a prostatic calculm at last results. The 
calculus may attain a very large sizfe, and may even extend forwards, 
into the urethra, and backwards, into the bladder. 

The characters of these concretions are well described by Mr. 
Henry Thompson, whose remarks are illustrated by careful drawings 
(" The Enlarged Prostate,'' Plates IV. and V., p. 265). The account 
above given does not differ materially from the conclusions arrived 
at by this author, who thinks that the concretions are first formed 
by the coalescence of the small yellow bodies or granules, which 
afterwards coalesce and form a larger mass. Professor Quekett 
considers that they commence by a deposit of earthy matter in the 
secreting cells of the gland, while Dr. Handfield Jones believes that 
the concretions originate in a vesicle, which increases by endogenous 
growth. 

In various parts of my sections of the prostate gland, concretions, 
the nucleus of which appears to consist of granular matter, may be 
observed. There are others in which concentric layers may be 
traced quite to a central point or granule. Some have a perfectly 
transparent centre. And not a few exist, in which the nucleus is 
composed of small granular cells, varying in number from one to 
twenty or more {^^ Illustrations^' Calculi Plate I., Fig. 4, 6, c). 
For further information on this interesting subject, I must 
refer to Mr. Thompson's excellent monograph on " The Enlarged 
Prostate," where the question of diagnosis and treatment are fully 
discussed. 



389 

Summary op the Chemical Chabactebs op Urinabt Calculi. 
1. — Galouli which leave only a slight residue after ignition, 

TJrio Acid.— Murexide formed when a solution in nitric acid is 
evaporated and exposed to the vapour of ammonia. A mere 
trace of residue left after ignition. Ammonia not given off 
when heated with a solution of caustic potash. 

Urate of Ammonia. — Reaction of murexide. Ammonia evolved 
when heated with potash. 

Urate of Soda.— Reaction of murexide. Fuses and gives a 
yellow tint to the flame. Leaves a decided residue after 
ignition. 

Urate of Lime. — Reaction of murexide. Infusible. After 
ignition, carbonate of lime remains. 

Urate of Btagnesia.— Reaction of murexide. Infuable. The 
residue after ignition dissolves, with slight effervescence, in 
dilute sulphuric acid. The magnesia is precipitated from 
this solution, in the form of triple phosphate, upon the 
addition of phosphate of soda and ammonia. 

Xanthine does not exhibit the murexide reaction. The solution 
in nitric acid turns yellow on evaporation. It is not soluble 
in carbonate of potassa. 

Cystine is soluble in caustic ammonia, and in carbonate of 
ammonia. It crystallises from an ammoniacal solution in six- 
sided plates. 

Pibrine emits an odour of burnt feathers on ignition. Solution 
in caustic potash precipitated by acetic acid, and also by 
ferrocyanide of potassium after the addition of a little acetic 
acid. 

2. — Calculi which leave a considerable residue after ignition. 

Triple or Ammoniaco-Ma^nesian Phosphate fuses in the blow- 
pipe flame, and gives off an ammoniacal odour. It dissolves 
in acetic acid without effervescence. Ammonia gives in this 
solution a crystalline precipitate of triple phosphate. 



390 THE ORIGIN AND FORMATION 

Phosphate of liixne does not fuse. Soluble in hydrochloric acid. 
Precipitated by ammonia in amorphous granules. From a 
solution in acetic acid, the lime may be precipitated as oxa- 
late when oxalate of ammonia is added. 

Oxalate of Lime.— Soluble in mineral acids, without efferves- 
cence. Precipitated from acid solution by ammonia. Inso- 
luble in acetic acid. After ignition, residue effervesces freely 
on the addition of acids. 

Oarbonate of liime. — Soluble in acids, with effervescence. 
Lime precipitated from an acetic acid solution by oxalate 
of ammonia. 



On the Origin and Formation op Urinary Calculi, and of 
THE Nature op the Nucleus. 

459. The Nature of the Nucleus of a Oalculus. — This sub- 
ject has been already referred to incidentally. Whenever there is a 
tendency to the precipitation of any of the slightly soluble consti- 
tuents of the urine in an insoluble form before the urine has left 
the organism, one of the conditions most essential to the formation 
of calculus is present. If an unusual quantity of any such substance 
should be formed, so that the urine contains a stronger solution of 
it than in health, very slight circumstances will lead to its deposition 
before the urine has left the bladder, and thus insoluble deposits 
occur. Each little mass of deposit may form a nucleus, around 
which new matter collects; but, as a general rule, the deposit escapes 
with the urine. Often it would appear that on the surface, and in 
the interstices, of rough stones more especially, small quantities of 
urine are retained, and prevented from mixing with the general 
mass. Chemical changes soon occur, the immediate result of which 
is the further precipitation of insoluble material. If the urine alters 
in its character, different substances may be deposited; thus, oxalate 
of lime may form the nucleus of the calculus ; and, after this has 
reached a certain size, the deposition of the oxalate may give place 
to that of uric acid. Again, the precipitation of this substance may 
cease, and several successive layers of phosphate may afterwards be 
formed. In some calculi, these layers alternate in a very remarkable 
manner. 



OF URINART CALCULI. 391 

The most interesting part of the whole process is the formation 
of the nucleus, and it is most important that we should study this 
matter very carefully. If we were able to ascertain the existence 
of calculi at a very early period of their formation, we could in many 
cases, doubtless, promote their expulsion before they attained any 
size, and thus most distressing suflfering would often be prevented, 
and sometimes the necessity for a severe operation removed. 

Any solid matter may form the nucleus of a calculous concretion. 
Inspissated mucus from any part of the urinary organs — crystals 
which have been deposited — cells of epithelium — ova of entozoa — 
pieces of fibrine and small clots of blood — ^foreign bodies which have 
been introduced from without, such as peas, portions of slate pencil, 
or tobacco-pipe, pins and needles, and other substances which are 
occasionally introduced into the urethra by silly persons, A piece 
of a catheter and bougie have also been found in the centre of 
a stone. 

My friend Mr. Charles Hawkins gave me, a short time ago, some 
very curious concretions. They were about half-an-inch in length 
and about the tenth of an inch in diameter. The surface was rough. 
They were of a whitish colour, and the calcareous matter of which 
they consisted was composed of triple phosphate and phosphate of 
lime. Upon breaking several with care a hair was found in the 
centre. The patient from whom they were obtained suffered from 
an ovarian cyst, which opened into the bladder. These concretions 
were, in fact, composed of earthy phosphates, which had been depo- 
sited from the urine upon the hairs, which had doubtless been formed 
in the ovarian tumour, and had passed into the bladder. Hair and 
teeth are not uncommonly found in connexion with ovarian tumours. 

460. liarsre Oalculi formed by the Afirgregration of Smaller 
ones. — Large calculi are sometimes formed by the aggregation of 
very small ones, just as a microscopic calculus may be formed by the 
aggregation of dumb-bells. Mr. Haynes Walton showed me a cal- 
culus of an oval form and whitish colour, with a very smooth external 
surface, about an inch and a half long by an inch wide, which he 
had removed from the urethra, directly behind the scrotum, of a 
gentleman of eighty years of age. It had been impacted in this 
situation for years. There was distinct evidence of the presence of 
this calculus fifty years before it was removed ! 



392 FORMATION OF 

On section, no concretric layers nor central nucleus were seen, 
but, upon examination with a low power, sections of very small cal- 
culi were observed in every part of the surface. In each of these a 
central nucleus and several concentric lines were clearly distin- 
guishable. These small calculi were connected together by a certain 
quantity of whitish matter, probably consisting of phosphate of lime 
and triple phosphate. 

461. The Formation of Microscopic Oalcnli. — I have lately 
had my attention very forcibly directed to the formation of urinary 
calculi, in consequence of having met with many specimens of 
microscopic calculi in urine. It is not at all uncommon to meet 
with microscopic uric acid calculi — aggregations consisting of uric 
acid crystals, which, if retained, might receive deposits of fresh 
material on the outside, until the small calculi, varying in size from 
a mustard-seed to that of a pea, or larger, are formed. 

Microscopic calculi of phosphate of lime are by no means un- 
common, and are often found in the kidney; but, until a few years 
ago, I had never had an opportunity of watching the formation of 
calculi composed of oxalate of lime. The nucleus of these calculi 
does not consist of mucus or epithelium, bs in the phosphatic 
calculus, but is of the same composition as the exterior. Fig. 125, 
Plate XXIII., represents a mass of dumb-bell crystals, many of which 
collections were passed in the urine. Although the mass is seen to 
consist of a number of distinct crystals, these are firmly attached, so 
that the whole may be rolled over and over without the individual 
crystals being separated from each other. 

Such collections I have many times seen in the uriniferous tubes 
in kidneys obtained from post-mortem examinations, which leaves 
no doubt as to the precise seat of formation of these bodies. I have 
seen them in the kidneys of the foetus, and have detected dumb-bells 
in the urine of children under two years of age. Gradually the 
interstices between the individual crystals become filled up with the 
same material, and at the same time a few of the larger crystals in- 
crease in size at the expense of the small ones. At length a small 
crystalline mass, of an oval form, is developed, which clearly consists 
of a microscopic mulberry calculus, and, if retained, will gradually 
increase in size. (Fig. 124.) When such calculi reach the pelvis 
of the kidney, a few sometimes increase gradually by the deposition 



MICROSCOPIC CALCULI. 393 

of oxalate of lime upon their exterior; while, no doubt, the greater 
number escape with the urine, and give no trouble. Such small 
bodies would easily become entangled in the mucus of the mucous 
membrane, and might remain in the pelvis of the kidney without 
exciting any disturbance until they had grown so large as to cause 
great inconvenience. If some of them passed down the ureter into 
the bladder, and happened to be retained for some time in this 
viscus, in a case where the urine contained much oxalate, they 
might increase in size until too large to escape by the urethra. It 
is, therefore, of great importance that cases in which these dumb-bell 
crystals are deposited should be very carefully watched. This obser- 
vation is of some interest also as showing the chemical composition 
of the dumb-bells, which has long been a disputed point. 

As I have before stated, many small uric acid calculi, which 
appear to be composed entirely of this substance, will be found upon 
careful examination to possess a nucleus consisting of oxalate of lime, 
and not unfrequently by the action of liquor potasssB well-defined 
dumb-bell crystals may be obtained. These are insoluble in potash, 
and also in acetic acid. I have obtained from several specimens 
fragments of a mass larger than that represented in Fig. 124, and no 
doubt formed in the same manner. From recent analyses I have 
made, I have been led to the conclusion that the dumb-bell crystals 
form the nucleus, around which the uric acid is deposited, more 
frequently than any other substance. I have not detected oxalate 
of lime in the centre of the small renal calculi composed of phosphate 
of lime which I have subjected to examination. 

On the Relativb Fbequency op the Occurrbnob op the 
Different Calculi. 

462. Frequency of Ocoiirrence of different kinds of Calculi. — 
It is often very diflGicult to ascertain why certain varieties of calculi 
should be found in greater proportion in some parts of the country 
than in others. The question is one of great interest in connection 
with the consideration of conditions under which the formation of 
urinary calculi occurs. 

In the collection of calculi at Guy's Hospital the proportion 
composed of phosphate of lime is as 1:29; at Bartholomew's as 1:32^; 
while in Norwich it is as 1:132|; and in Bristol as 1:156. Of 230 

s 5 



894 



OCCURRENCE OF 



pure uric acid calculi in different hospitals in England and on the 
continent, as many as 164 are contained in the Norwich collection. 
{See the tables in the appendix to Dr. Front's work on " Stomach 
and Urinary Diseases.'') In the collection of urinary calculi in the 
museum of Guy's Hospital, it appears, from the statement of Dr. 
Golding Bird, that out of 208 calculi the nucleus consisted of uric 
acid in 127, of oxalate of lime in 47, of phosphates in 22, and of 
cystine in 11 ; or, of uric acid in 60 per cent., of oxalate of lime in 
22 per cent., of phosphates in 10 per cent., and of cystine in 5 per 
cent. These figures are somewhat different to those given by Dr. 
Golding Bird, because I have thought it more correct to reckon 
in this calculation 142 calculi, which were obtained from one indi- 
vidual, as one. 

Dr. Carter's observations on the composition of the calculi in the 
Grant Medical College, Bombay, prove that very few nuclei are 
composed of uric acid, while a large number consist of oxalate of 
lime. The following table, from Dr. Carter's paper, shows the per 
centage of calculi in India and in England entirely composed of uric 
acid, urate of ammonia, and oxalate of lime : — 



Uric Acid . . . 
Urate of Ammonia 
Oxalate of Lime . 


Grant Med. 
College. 
Per Cent. 


Coll. of 
Surgeons. 
Per Cent. 


Guy's 
Hospital. 
Per Cent 


Norwich 
Hospital. 
Per Cent 


3-3 

6-0 

14-0 


32-92 
2-15 
5-12 


15-38 
3-84 
9-13 


24-73 
8-29 
3-16 



The following are the conclusions to which Dr. Carter has been 
led: — " 1. That, in the Bombay Presidency, the proportion of calculi 
having oxalate of lime for their nucleus, or wholly composed of it, 
is about twice as great as in England, taking for comparison certain 
standard collections there. 2. That the proportion of calculi having 
uric acid or a urate for their nucleus or entire substance, is con- 
siderably less in India than in England; in the former, urate of 
ammonia calculi are somewhat more frequent than uric acid calculi ; 
the opposite is the case in England. 3. That the number of calculi 
wholly composed of earthy phosphates, or having them for a nucleus, 
is proportionately much fewer in India than in England, the differ- 
ence being chiefly owing to the rarity of the mixed phosphate in 



DIFFERENT KINDS OF CALCULL 395 

the fonner." (" An Account of the Calcuii contained in the Grant 
Medical College Museum^ with some General Remarks on Calculi 
in India.'' By H. V. Carter, M.D. Lond., Assistant-Surgeon, Acting 
Curator of the Museum, August, 1859.) 

463. Formation of a Calculus oompoBed of Phosphate, TTric 
Acid, and Oxalate of lAme, — It is, however, important to bear in 
mind that, in the observations to which I have alluded, the central 
part of the calculus which is visible to the unaided eye is spoken of 
as the nucleus, while the real nucleus may be microscopic, and of a 
different composition to the material which immediately surrounds 
it. The nucleus of many calculi, which apparently consists of uric 
acid, is really composed of oxalate of lime, around which the uric 
acid has been deposited. The phosphatic calculus which is repre- 
sented in Plate XXIV., Fig. 130, seems to have a nucleus of uric 
acid about the size of an almond, but the latter contains in its 
centre a small nucleus consisting of oxalate, which can only be 
demonstrated by the microscope. Now the history of the formation 
of this is, probably, as follows : — A number of dumb-bell crystals 
of oxalate of lime, formed in the uriniferous tubes, became aggre- 
gated together, and around this small mass, uric acid was deposited 
as it lay in the tubes and pelvis of the kidney ; then it passed down 
the ureter into the bladder, where the phosphate was deposited, and 
where the calculus attained its present size. Now, the deposition of 
the phosphatic salts on the uric acid is not more dependent on the 
presence of the latter than the precipitation of the uric acid was 
consequent upon the presence of the oxalate. In all probability 
neither the phosphate nor the uric acid would have been preci- 
pitated had not the oxalate been present in the first instance. It 
is not too much to say that, if the latter had not remained for some 
time in the uriniferous tubes, and gradually increased in size, no 
calculus would have been formed in the present case ; if, therefore, 
the collection of dumb-bell crystals had been washed out of the 
kidney by diluents, soon after their formation, the further precipi- 
tation of calculous matter would have been entirely prevented. 

It is important that we should make numerous observations on 
the nuclei of various calculi, and endeavour to determine their 
exact nature by microscopical investigation, and by the application 
of chemical tests. In this inquiry it will be found advantageous to 



396 THE TREATMENT 

take the smallest calculi and examine them as soon as possible 
after they have been passed. After they have become dry, it is, in 
most cases, quite useless to attempt investigations on the nature of 
the nucleus. 

The Treatment op Calculous Disorders. 

464. On the Importance of the Administration of increased 
Quantities of Fluids in certain Calculous Affections. — I have 
already adverted to the importance of increasing the quantity of 
fluid taken by persons who suflfer from certain varieties of urinary 
deposits. This principle has been fully recognised by Prout and 
many practical physicians who have had experience in treating 
cases of this class j but the remedy, perhaps from its very simplicity, 
has certainly not received the attention at the hands of many prac- 
titioners that it deserves. There are conditions of the system which 
are very much influenced by the dilution of the blood, and many of 
the chemical decompositions going on are promoted by an increase 
in the quantity of fluid. Some changes will not take place unless 
the solutions of the substances be very dilute. Many comparatively 
insoluble matters are slowly dissolved away by the frequent renewal 
of the fluid in contact with them. 

Even silica is capable of being dissolved in water; and it is 
from a solution containing so slight a trace, that the substance can 
only be detected at all by operating upon very large quantities, that 
the whole of the silicious matter contributing in so important a 
degree to give firmness to the stems of grasses, is deposited. The 
amount of water that must pass through the tissues of the plant 
during its growth, and give up its silicious matter, must be enor- 
mous, since the quantity dissolved in each pint of fluid taken up by 
the roots is so very small. 

On the same principle, by causing much liquid to traverse the 
tissues of a living animal, comparatively insoluble substances may 
be washed out. It is doubtful if that abundant deposition of urate 
of soda which is from time to time met with in almost all parts of 
the body, in certain cases, would have occurred at all, if the fluids 
had been constantly maintained in a proper state of dilution ; and, 
when these crystals have been deposited, we endeavour to remove 
them, or prevent further deposition, by diluting the fluids of the 
body, and by endeavouring to increase the solubility of the urate. 



OF CALCULOUS DISORDERS. 397 

We are, perhaps, too apt, in many chronic cases, to put patients 
upon a plan of treatment for so short a time as a few days or weeks ; 
and our patients are often unreasonable enough to expect that 
remedies will remove, in a week, matter which has been slowly 
accumulating, perhaps, for years. It is chronic cases of this kind 
which receive such real benefit ft'om the comparatively prolonged 
course to which they are subjected in a German bath or hydropathic 
establishment; and it too often happens that, in endeavouring to 
perform quickly, by remedies, that which it is only possible to effect 
by giving large quantities of fluid during a considerable period of 
time, we disappoint ourselves and our patients. Perhaps in the end 
they attribute to some quack remedy or system, to which they have 
subsequently had recourse, a favourable result which is really due to 
the water they have drank with it, and the hygienic rules to which 
they have been subjected, rather than to the nostrums they have 
swallowed. 

In certain cases of gout, in chronic rheumatism, and in many 
cases where uric acid and urates are constantly deposited in the 
urine or in the tissues of the body, the most important of all things 
is to ensure the thorough washing out of the system. Exercise, 
when it can be taken, hot baths, Turkish baths, etc., by promoting 
sweating, excite thirst; and thus more fluid is ingested, which is 
soon got rid of by various emunctories carrying out with it insoluble 
substances, the fluid removed being soon replaced by a fresh quan- 
tity. In the frequent repetition of these processes from time to 
time, a vast quantity of fluid is made to pass through the body, 
with the most beneficial results. 

It is surprising how very little fluid some persons take habitually; 
and this fluid, small as it is, is often saturated with soluble sub- 
stances. The fluid thus introduced, is, in many persons who live 
well, barely suflGicient to hold the various compounds in solution 
while undergoing chemical change. Many dislike to drink water, 
and not a few have a strong prejudice against it; and these are often 
the very individuals whom we find suffering from gout, rheumatic 
pains in the muscular and fibrous tissues, and various forms of 
urinary deposits. They will receive great benefit from moderate 
sweating, and taking alkalies dissolved in a large quantity of water. 

We seldom find difficulty in prevailing on patients to take 
Seltzer, Vichy, or other alkaline waters daily, although it would be 



398 OP DISSOLVING 

useless to recommend them to take pure water. They can take 
these waters with their wine at dinner, the last thing at night, and 
perhaps the first thing in the morning. People who live well, or 
rather too well, will soon find out that they must continue this plan, 
and take now and then small doses of alkalies. It is quite super- 
fluous for me to enter into the minute details applicable in indi- 
vidual cases; but I cannot too strongly recommend a careful inquiry 
into the general habits of patients of this class; for I feel sure that 
much permanent relief may be afforded by explaining to them the 
importance of constantly attending to simple rules based on the 
principles to which I have adverted. 

I shall abstain even from enumerating the many drugs that have 
been recommended in calculous disorders, for I am convinced that 
we shall practise our profession with greater advantage to our 
patients, and advance its interests more, by studying carefully the 
nature of the actual processes going on in disease, and considering 
how these processes are to be modified by simple means and a few 
remedies whose action is certain and well understood, than by 
hunting for new specific medicines, or combining together a great 
number of compounds, many of which are completely modified as 
soon as they enter the stomach, and are certainly destroyed long ere 
they reach the part of the organism where we desire that they should 
exert their specific influence. 

465. On the Methods of Dissolvinfir TTrinary Calculi. — I can 
only offer a very few remarks on this important and interesting subject. 
Many of the observations which I have made with reference to the 
prevention or removal of urinary deposits are also applicable to 
calculi of allied composition. When a uric acid or urate of ammonia 
calculus, for instance, has been deposited, it may be dissolved, or its 
increase may be prevented, by producing alterations in the chemical 
composition of the urine. This may be effected partly by diet, and 
partly by the administration of various remedies, especially alkalies 
and the salts of the vegetable acids. 

It is possible also, in certain instances, to dissolve the stone by 
injecting solvents into the bladder. In many cases, however, all our 
attempts to remove the stone by effecting its solution will be ineffec- 
tual, and we shall have to call in the assistance of the surgeon, who 
may remove the stone entire by lithotomy, or may crush it with the 



URINARY CALCULI. 399 

lithotrite into several small pieces, which escape by the ordinary 
channel. 

Mere dilution of the urine Tfill sometimes exert a considerable 
influence upon a calculus ; and it is possible that some calculi may 
have been entirely dissolved in this manner. An acid state of urine 
would tend gradually to dissolve a phosphatic calculus; and it is 
very possible that, if a feebly alkaline condition of the urine could 
be maintained for a considerable time, an impression might be made 
upon calculi composed of different forms of urates, or even upon an 
uric acid calculus. The irregularities often seen upon the surfaces 
of such calculi have been very properly termed " water-worn," and 
clearly indicate that the urine has exerted, for a time at least, a 
solvent action. Although in certain cases it would undoubtedly be 
right to adopt for a time treatment of this kind, we must not look 
forward to the result with any great degree of confidence ; at best, 
such changes are doubtful, tedious, and very uncertain. 

Many attempts have been made to dissolve the calculus by in- 
jecting fluids, which exert a solvent power upon the stone, into the 
bladder. The most convenient plan is to inject the fluid through a 
double catheter for half an hour every two or three days, or more 
frequently. Dr. Willis has recommended that the fluid should be 
placed in a reservoir at a sufficient height above the patient, and 
connected with the catheter by a tube provided with a stop-cock, by 
which means the flow of the solvent may be carefully regulated. In 
carrying out this plan, it is very important that the solution should 
be so weak as to prevent all chance of the mucous membrane of the 
bladder being injured. Sir Benjamin Brodie showed that phosphatic 
calculi might be greatly reduced in size, or entirely dissolved, by 
injecting a weak solution of nitric acid (2 to 2^ minims of strong 
nitric acid to an ounce of distilled water). Such a solution would 
also act very favourably in removing the sharp edges of fragments 
remaining in the bladder after the operation of lithotrity. 

The objection to the use of alkalies in attempting to effect the 
solution of uric acid or urates is, that the phosphates are precipitated 
from the urine, and the calculus protected from the further action of 
the solvent. 

The most ingenious plan for dissolving calculi was that proposed 
some years since by Dr. Hoskins, who employed a weak solution of 
acetate of lead (one grain to the ounce) with a mere trace of free 



400 OF DISSOLVING 

acetic acid. With a phosphatic stone, double decomposition occurs. 
Phosphate of lead, in the form of a fine granular precipitate, and 
an acetate of lime and magnesia, are formed. The solution, it need 
hardly be said, does not produce any irritation or unfavourable 
action upon the bladder. 

466. Ezperixnents on the Solvent Action of Alkaline Car- 
bonates.— Dr. Roberts found "that very weak solutions of the 
alkaline carbonates dissolved uric acid calculi with considerable 
rapidity, while stronger ones altogether failed. In order to decide 
what strength of solution had the most solvent power, fragments o^ 
uric acid, weighing from 40 to 112 grains, were placed in 10-oz. 
phials, and solutions of carbonate of potash and soda of various 
strength were passed over them at blood heat. The experiments 
were continued day and night ; and the daily flow of solvent varied 
from 6 to 15 pints. 

" Operating in this way, it was found that above a strength of 
120 grains to the pint no solvent action was exerted ; and even with 
80 grains to the pint there was only a little ; but solutions of 50 
and 60 grains to the pint dissolved the fragments freely. A coat or 
crust of white matter invariably invested the stone in the stronger 
solutions, and prevented further action. At and above 120 grains 
to the pint this coat was dense and tough, and could not be wholly 
detached from the subjacent surface. With 80 grains to the pint, it 
was brittle and easily detached like a layer of whitewash. With 60 
grains to the pint and under, either no crust formed at all and the 
stone dissolved clean with a water-worn appearance, or it was only 
represented by a few loose flakes, scattered here and there over the 
surface, and offering no impediment to dissolution. This coating or 
crust was found essentially to consist of bi-urate of potash or soda, 
and its formation depended on the fact that the alkaline bi-urates 
are almost insoluble in any but very weak solutions of the alkaline 
carbonates. In the strong solutions the bi-urate remains undissolved 
and encases the stone in an insoluble investment ; while in weaker 
ones it is dissolved as fast as it is formed, the surface of the stone 
remains clean, and dissolution proceeds without impediment." * 

The following table is the result of an experiment continued for 
forty-eight days. 

♦ ** Archives o/Medicinet" Vol. UL 



URINAEY CALCULI. 



401 



Table II. — Uric Acid and Carbonate of Potash, 



strength of 
SoluUon. 


Flow per 
24 Hours. 


No. of 
Obs. 


Dafly Average 

Loss of Weight 

per Cent 


Remarks. 


Grs. per Pint 


Pints. 








240 


6 


1 





Covered with a tenacious 
white coat, as if of 
paint 


120 


6 


3 





Covered with a less dense 
coating. After detach- 
ing this and wiping, 
there was a mean loss 
of weight of 7*1 per 
cent. 


80 


6 


2 


9-8 


Covered with a loose de- 
tachable white crust 


(60 


14 


2 


19-0) .. 
f 20-2 


Surface clean. 


(60 


6 


5 


21-4 . . 


Loose flakes in spots. 


40 


6 


3 


15-6 


Sometimes a few loose 
flakes where the frag- 
ment rested. 


(30 


15 


4 


13-0) 

^^•^ 11-9 
10-2) 




)30 
)30 
(30 


8 
4 
6 


2 
2 

4 


Dissolved clean ; occa- 
sionally a few loose 
flakes. 


20 


6 


3 


11-0 


Dissolved clean. 


10 


6 


3 


6-5 


Ditto. 



407.— On DissolvinfiT Calonli by Electrolysis — Attempts have 
been made to disintegrate and eflfect the solution of calculi in the 
living body by aid of galvanism. MM. Prevost and Dumas {'^Annates 
de Ch^mie,'' Vol. XXIII., p. 202, 1823) employed electricity for the 
purpose of disintegrating phosphatic calculi, by the mechanical 
action of the gases set free in the electrolysis of water ; but only a 
grain per hour was thus removed. The solution of the calculus was 
not attempted in those experiments. Dr. Ludwig Melicher (" Oester- 
reich, Medicin. Jahrbuch,'^ 1848, Vol. I., p. 154) tried to dissolve a 
calculus by the aid of electricity. It is said that two experiments 
on the living body were successful. (Quoted by Dr. Bence Jones.) 



402 LITHOTOIIT. 

The latest, as Tfell as the most successfdl, efforts have been made 
by Dr. Bence Jones, who employed a solution of nitrate of potash, 
and decomposed this by the aid of a powerful galvanic battery. The 
nitric acid set free at the positive electrode would decompose the 
uric acid exposed to its influence, and the potassa evolved at the 
negative electrode would dissolve it, so that an uric acid calculus 
placed between them would be disintegrated at both points. The 
battery employed was from five to twenty pairs of Grove's plates. 
From 2 to 9 grains of uric acid calculus were dissolved per hour at 
the temperature of the body. Of oxalate of lime, ^ grain to 2 grains 
per hour only were dissolved. The action was four times as slow as 
upon uric acid calculi. Of oxalate of lime and uric acid, in alter- 
nating layers, 4j to 6 grains were dissolved per hour. Of pbosphatic 
calculi upwards of 25 grains were dissolved per hour. 

468. Treatment durinfir the passagre of a Calculus alonsr the 
TTreter.— The violent pain which often, but not invariably, results 
from the passage of a calculus down the ureter, is generally relieved 
by hot fomentations or a warm bath. Diluents and sudorifics should 
be given internally. In one case, referred to by Dr. Prout, the into- 
lerable burning sensation was relieved by the application of pounded 
ice to the region of the kidney. If there is violent hsBmorrhage, the 
patient must be kept lying down; and if the pain is constant, an 
opium or henbane suppository in the rectum often affords temporary 
relief. Moderate exercise, or even the violent jolting of riding, 
when the suffering is not very great, will often promote the descent 
of a calculus from the kidney. I know of several cases in which a 
calculus has passed down the ureter without causing any pain what- 
ever, and the patient was not conscious of its existence until he had 
passed it. Purgatives, cupping over the loins, and alkaline diuretics, 
with small doses of opium or henbane, are required, if the descent of 
the calculus is very slow; or if the stone is impacted in the kidney. 
Often there is violent sickness, but this is of short duration. 

469. liithotomy and liithotrity. — This is a part of the subject 
which I am quite incompetent to discuss, but there are one or two 
recent modifications in the operation to which I may be permitted 
to advert very briefly. The operation of lithotomy, which is usually 
performed by most surgeons in the present day, is the lateral one. 
For a discussion of the various important points connected with 



LITHOTRITT. 403 

this operation, I must refer to Professor Fergusson's treatise on 
** Practical Surgery *' 

Some time since, the median operation was performed with con- 
siderable success by Mr. Allarton. Its principal advantages seem 
to be, that the levator ani and prostatic capsule and plexus escape 
injury, while the course into the bladder is most direct. There is 
also the advantage, that the knife is not used either to notch the 
prostate or to open the bladder. On the other hand, there seems to 
be considerable chance of injuring the ejaculatory ducts; and a 
surgical friend tells me that there is a want of space in manipulating 
with the forceps, and in seizing and extracting the stone, and that 
there is also some risk, especially in children, of injuring the bulb 
of the urethra or the rectum. This operation is described in the 
^^ Lancet'' 1869, Vol. I., p. 122. {See also Mr. Allarton's work on 
" Lithotomy SimplifiedP London : Ash and Flint. 1854.) 

In connection with the subject of lithotomy, I may remark that, 
in a recent improvement in the manner of carrying out the lateral 
operation, by Mr. Wood, the injurious eflfects which sometimes result 
from the division of the prostate and levator ani with the knife are 
altogether avoided. Mr. Wood employs a staff composed of two 
blades, which can be separated from each other while the instrument 
is held in position. Dilatation of the urethra is readily effected by 
allowing the finger to slide in between the blades. In the single 
case in which this operation has been performed in the living 
subject, it certainly succeeded admirably. {^^ Medical Times and 
OazetU^' December 22nd, 1860.) 

The principal advantages of this over the ordinary lateral and 
median operations respectively, are, that as the knife does not enter 
the bladder at all, neither the prostatic veins nor the fascial capsule 
are injured, nor can the ejaculatory ducts be cut. The levator ani 
cannot be divided, and all chance of the extravasation of urine into 
the pelvic areolar tissue is avoided. The form of the external 
incision is such that more room is given than in the ordinary 
operation, while injury to all important vessels and other structures 
is avoided. By this proceeding, the dilatation necessary for the 
extraction of the stone is much more easily effected than in the 
median operation. 

Of late years, lithotrity appears to have been carried out very 
successfully in numerous cases in which the operation of lithotomy 



404 LITHOTBITY. 

would have been practised formerly. The number of fatal cases 
resulting from lithotomy is considerably greater than that obtained 
from an analysis of the cases of lithotrity to which I have been able 
to refer. And it appears that stones of very large size may be 
crushed with safety. So far as I can learn, setting aside a few 
exceptional cases, it would seem that lithotomy afforded but a poor 
chance of safety where lithotrity could not be confidently recom- 
mended. These remarks, I need hardly say, apply only to adults. 
In children, lithotomy is so safe an operation, while the small size 
of the urethra and other circumstances are unfavourable to litho- 
trity, that it is not likely that surgeons will have recourse to any 
other proceeding. 

The experience especially of Sir Benjamin Brodie, Mr. Charles 
Hawkins, and Mr. Prescott Hewett, has proved that, when performed 
with care, lithotrity is a most successful operation. Mr. Hawkins 
tells me that he has operated with success even in cases of stricture 
and irritable bladder, and has performed lithotrity where lithotomy 
could not have been undertaken. {See a case reported in the 
^^ Transactions^' of the Royal Medical and Chirurgical Society for 
1859.) On the subject of lithotrity, I must refer to Sir B. Brodie's 
paper in the twentieth Volume of the " Transactions^^ of the Royal 
Medical and Chirurgical Society, in the concluding paragraph of 
which are these words — " My own experience has certainly led me 
to the conclusion that lithotrity, if prudently and carefully per- 
formed, with a due attention to minute circumstances, is liable to a 
smaller objection than almost any other of the ca*pital operations 
of surgery." 



405 



Brief Summary op the Principal Constituents op Urine, 

AND THEIR MICROSCOPICAL AND ChEMICAL CHARACTERS. 



Healthy TTrine. Quantity. — A healthy man usually passes 
from 40 to 60 oz. (17,500 to 26,250 grains) during twenty-four 
hours. 

Quantity of Water.— Average, about 20,000 grs. in twenty-four 
hours, or 940 grains per 1,000 grains of urine. Varies much even 
in health, and at different periods of the day. 

Quantity of Solid Matter varies inversely as the water — 600 

to 1,200 grains excreted in twenty-four hours. 

»' 
Specific Gravity of the urine in health varies from 1,015 to 

1,025 ; depends not only upon the quantity of solid matter in the 

urine, but also upon the specific gravity of the constituents. 

(§ 117.) 

Beaction.— Acid. Varies at different periods of the day. 

(§ 119.) 

On the quantities of the various constituents in the urine in 
health, Bee Chapters VI., VIII., and the table on p. 136. 

Examination of TTrine. — ^When endeavouring to ascertain if 
there be any abnormal condition of the urine, note its reaction, 
the quantity passed in twenty-four hours, its specific gravity, and 
the amount of solid matter. Also apply certain chemical tests, 
and resort to microscopical examination, if there be any deposit. 
(Chapter V.) 

Chemical Analysis alone will show the presence of urea, uric 
acid, extractive matters, salts, sugar, albumen, bile; and is employed 
for ascertaining the composition of certain deposits. (Chapters VI., 
XL, XII.) 

The Microscope discovers various substances which are either 
not recognised at all, or are with great difliculty proved to be 
present by other means. (Chapter III.) 



406 



Directions for instituting a Rouan general Examination 
OP A Specimen op Urine. 



The most necessary tests may be arranged under six heads ; and, 
by having recourse to one or more of these, we are enabled to deter- 
mine roughly the most common morbid states of the urine. 

1. Beaotion (§§ 118, 119, 120). 

2. Specific Gravity (§ 117). — ^When very high, we may suspect 

an increased quantity of urea (excess) ; or the presence of 
sugar. Apply tests mentioned on p. 408. Hysterical 
urine, and urine of cases where much water has been 
taken, is of very low specific gravity. 

3. Heat.— Urate of soda, distinguished from pus or phosphate 

(§ 374). Albumen. Precipitation of phosphate, &c. 

(§ 244). 

4. Nitric Acid dissolves phosphates (§ 245) ; decomposes urate 

of soda (if strong, rapidly) ; precipitates albumen in urine, 
even when in very small quantity and due to the presence 
of pus. Used also to test the presence of uric acid (§ 137). 
Excess of urea (§ 206). Bile (§ 263). 

6. Potash.— Urates, distinguished from pus or phosphate (§ 374). 
Uric acid, from blood. Sugar indicated by a brown colour, 
after prolonged boiling. 

6. Nitrate of Silver.— Precipitate of chloride of silver, insoluble 
in nitric acid (§ 175). In certain cases, the urine does not 
contain a trace of chloride of sodium (§ 220). 



407 
Chemical Examination of Ubine. 



1. — Chemical Examination with reference to Detecting the 
Nature of the Deposit, 

a. Ligrlit and Plocctdent Deposits (Chapter XIV., p 289). — 
Deposits of this class are generally too light, and the quantity is too 
small, for the application of chemical tests. (See ^^Microscopical 
Examination of Deposits, p. 424.) 

h. Dense and Opaaue Deposits (Chapter XV., p. 313), usually 
present in considerahle quantity, are of three kinds, which much 
resemble each other in appearance. 

1. Urate of Soda (§ 376). — Lateritious, nut-brown sediment. 

Varies much in colour. Urine acid. Tests. — Soluble by 
heat, in potash, ammonia, water. Decomposed by acid; 
uric acid set free. 

2. Phosphates (§ 388). — ^Urine usually alkaline or neutral. 

When triple phosphate alone is present, the urine is 
sometimes feebly acid. Tests, — Insoluble by heat or in 
alkalies; soluble in acids, and afterwards precipitated by 
ammonia. 

3. Pus (§ 381). — Difiused through the urine, rendering it 

turbid, or forming a bulky creamy deposit, with clear or 
tubid supernatant fluid. Tests, — Rendered glairy by 
potash. Albumen in urine precipitated by heat and by 
nitric acid. Caution, — Albumen may be independent of 
the pus. 

c. Crystalline or Orannlar Deposits are usually in small 
quantity, formingr a sediment which may either be coloured or 
transparent and colourless. — (Chapter XVI., p. 337.) 

1. TJrio Acid (§ 397). — Colour characteristic, usually of a dark 

mahogany brown, sometimes paler, very seldom quite 
colourless. Large separate clusters of crystals. It rarely 
forms a granular deposit. Tests,— {^ 398). — Soluble in 
potash, nitric acid. After evaporation with nitric acid, 
ammonia gives the dark violet colour of murexide or 
purpurate of ammonia. Often mixed with blood, smoky 
urine. Albumen detected in the fluid. 

2. Blood-corpuscles (§ 416). — See ^^Microscopical Exami- 

nation," 

3. Oxalate of liime (§ 402). — Seldom in sufficient quantity to 

form a deposit visible to the unaided eye. Tests (§ 408). — 



408 CHEMICAL EXAMINATION 

Insoluble in water, potash, and acetic acid, even when 
boiled ; soluble in mineral acids ; and again thrown down 
amorphous, but unchanged in composition, by ammonia. 
By incineration, an odour like that of burnt feathers is 
evolved. Black ash becomes white by decarbonisation ; 
this ash is soluble in acetic acid, with copious eflfervescence. 
Oxalate of ammonia added to acetic acid solution pre- 
cipitates oxalate of lime. 

4. Silica (§ 415) is said to have been found in very minute 
quantities in urine ; rarely met with as a deposit, except 
in the form of grains of sand in the urine of hysterical 
patients and impostors. Easily known by its great density, 
general appearance, and insolubility in strong mineral 
acids. 

2. — Chemical Examination with reference to the Discovery of an 
Abnormal Condition of the Soluble Constituents of the Urine, or 
of the eanstenee of Substances of a Soluble Form not met with in 
Health, (Chapter XI.) 

1. Albumen (§ 240 et seq.). — Urine pale; often of very low 

specific gravity, 1,005 to 1,012 or 1,014. Heat or nitric 
acid, if urine be acid ; nitric acid, if the urine be alkaline. 
Keason : solubility of albumen in alkalies. Fallacies, — ^A 
trace of nitric add prevents the precipitation of albumen 
by heat (248). Precipitation of phosphates by simply 
boiling the urine. Precipitation of minute crystals of uric 
acid upon the addition of dilute nitric acid to some 
specimens of urine: hence necessity for employing both 
tests (§ 246). 

2. Excess of TJrea (§ 206). — Urine frequently high coloured; 

specific gravity, 1,030 to 1,040. Upon the addition of an 
equal volume of strong nitric acid, crystals occur within 
half-an-hour, if there be much excess. Oxalic acid is often 
employed when the urea is to be determined quantitatively. 

3. Sugrar (§ 274). — Urine pale, of high specific gravity, from 

1,030 to 1,050. Trommer's test (§ 277). Potash tests 
(§ 276). Ferm'entation test (§ 283). Tartrate of copper 
(§ 278). 

4. Sulpliates (§§ 169, 224). — ^Nitrate of barytes or chloride of 

barium, after the addition of a few drops of nitric acid. 

6. Chloride of Sodium (§§ 173, 220). — Nitrate of silver, after 
the addition of a few drops of nitric acid. 

6. Bile (§§ 258, 259, 263, 264).— Urine of a dark yellow colour. 
Nitric acid ; play of colours. Pettenkoffer's test. 



409 

MiCEOScopiOAL Examination op Ueinary Deposits. 
(Chapter III.) 



Great caution required in every step (p. 25). A large quantity 
of urine (at least four ounces) should oe allowed to subside in a 
conical glass (Figs. 6, 9, Plates I., II.) for some (two or three) hours, 
or the greater portion of the urine may be poured off from the 
deposit, which may then be submitted to examination. In the last 
case, small bottles only need be taken to collect specimens ; but, of 
course, no idea can be formed as to the relative amount of deposit 
present (§ 62). Pipettes (Fig. 14, Plate III.). Examination in 
cells or cages (Figs. 24, 26, 26, Plate V.). 

Insoluble matter may be — 

1. Diffused through the urine, or it may form a visible deposit. 

When the insoluble matter has subsided, the deposit may 
assume one of three characters (Chapter XIV.). 

2. It may occupy a large bulk, and present a flocculent appear- 

ance; or 

3. It may form a dense, opaque, and abundant or scanty 

stratum; or 

4. The deposit may be small in quantity, crystalline, consisting 

of sparkling colourless points, or of more or less coloured 

granules. 
All these characters may coexist in one deposit, in which case 
we observe three distinct strata, each of which must be separately 
submitted to microscopical examination. In many cases there arc 
two distinct strata. 

1. Substances floating on the Surface of the Urine, or diffused 

through it, hut not forming a visible Deposit, 
(Chapter XIV., p. 290.) 

a. Opalescence produced by urates (p. 290). 

5. Opalescence produced by vibriones (§ 326). 

c. Milk in urine (§ 326). 

d. Chylous urine (§ 327). 

2. Deposit light and flocculent, occupying a considerable Bulk, 

(Chapter XIV.) 

Always take specimens from the bottom of the glass for examin- 
ation, as well as from the bulk of the deposit. 

a. Simple mucus-corpuscles (§ 344), or with bladder or renal 

epithelium (§ 353). Cells sometimes tinged with yellow 

bile (§ 262). 



410 MICROSCOnCAL EXAMINATION. 

b. Simple mucus, or epithelium with numerous small crystals of 

oxalate of lime entangled in it (p. 293). 

c. Casts. Various fonns of casts (§ 363 et seq,) a. Casts of 

medium diameter, p. Casts of considerable diameter, 
y. Casts of small diameter. 

d. Spermatozoa (§ 358). Vibriones (§ 349). Torulse (§ 350). 

Sarcinge (§ 351). 

e. Matters of extraneous origin (§ 78). Bed-flock : hair : feathers : 

dust. Distinction from casts, &c. (§ 84). 

3. Deposit dense^ opaque, and abundant, (Chapter XV.) 

a. Urates. Amorphous deposit. 

b. Pus (§ 381). Characters. Potash. Acetic acid. 

c. Phosphates (§ 388). Phosphate of lime (amorphous) (§ 390). 

Triple or ammoniaco-magnesian phosphate (crystalline) 
(§ 387). Mixed with carbonate or oxalates. 

d. Matters of extraneous origin (§ 78). Sand. Starch: potato: 

rice: bread-crumbs: arrowroot (§ 85). 

4. Granular or Crystalline Deposits, small in Quantity, sinking to 

the Bottom, or adhering to the Sides of the Vessel, 

(Chapter XVI.) 

a. Uric acid (§ 396). Forms of. Amorphous. Varies much in 

colour. Polarisation. 

b. Oxalate of lime (§ 402). Forms of. Dumb-bells (§ 404). Dis- 

tinction of oxalate of lime from triple phosphate. 

c. Phosphate of lime (§ 390). Phosphate of lime, radiating 

crystals (§ 392). 

d. Blood-globules (§ 416). 

e. Cystine (§ 411). Carbonate of lime (§ 414). 
/. Matters of extraneous origin (§ 78). 



411 



TABLES 

FOS 

THE SYSTEMATIC QUALITATIVE EXAMINATION 
OF URINE. 



•»• All who desire to become practically familiar with the most important char- 
acters of the urine, are strongly recommended to submit to the routine which a consci- 
entious practice of the experiments given in the following tables necessarily involves. 
The author is fully persuaded that the patient prosecution of the course recommended, 
for two hours on eight or ten occasions, will enable the practitioner to obtain a practical 
familiarity with the subject, which it is impossible he can acquire by reading. 



TABLE I. 
GENERAL CHARACTERS OF URINE (Chapter V.). 

,* The works referred to in these Tables are the present one, and the " Ittuitration$ of Urint, 
Urituity Depotita, and Calculi." 

Place about 100 grains of urine in a basin to evaporate over the 
water-bath. 

1. Colour, Smell, Clearness or Turbidity, Deposit, Film 

ON Surface. — Pour about four ounces of urine into a test- 
glass; take notice of its colour (S 112) and smell (§ 113). 
Observe whether the specimen be clear or turbid, and 
notice the faint xnucons cloud which collects on standing 
(§ 116). Observe whether there be any deposit which 
sinks to the bottom of the vessel, or film floating upon the 
surface of the fluid (§ 324, p. 289). 

2. Specific GRAViTr. — Take the specific gravity of the urine 

(§ 117). 

a. Using the urinometer (§ 117, Fig. 6, Plate I.; Fig. 

15, Plate III.). 
p. Using the specific gravity bottle (§ 117, Fig. 16, 
Plate III.). 

3. Reaction. — Test the urine with blue litmus paper. 2. If the 

specimen exhibit no acid reactioii, test it with reddened 
litmus, and observe whether the colour be restored upon 
gently warming the paper upon a strip of glass, volatile 
BlkaU (§ 121), or not, fixed alkaU (§ 122). 

4. Crystalline Substances in Urine. — Place a drop of urine 

which has been concentrated by evaporation upon a glass 
slide, and cover it with thin glass. When cool, examine it 

T 3 



412 TABLES FOR THE 

nnder the microscope; note the form of crystals present, 
urate of soda (§ 213), acid phospliate of soda (§ 156), basic 
phosphate of soda (§ 157), sulphate of soda (§ 169), chloride 
of sodium and urea (§§ 129, 173), ammoniaco-magnesian or 
triple phosphate (§ 164), granules of phosphate of lime 
(§ 162). {''Illustrations" Urine, Plate I.) 

6. Decomposition by Heat. — Place a small portion of the solid 
residue (about the size of a pin's head) in a hard glass tube, 
and expose it to the flame of a spirit-lamp, gradually raising 
the temperature to redness. Test the reaction of the vapour 
emitted from the tube with reddened litmus paper, which 
has been moistened. Ammonia evolred (§ 152). 

6. Saline Constituents. — Remove the carbonaceous residue 

from the tube, and expose it upon platinum foil to a dull 
red heat, until nothing but a white ash remains (§ 151, 
''Illustrations,'' Urine, Fig. 2, Plate I.). 

7. Alkaline Salts. — Place the ash upon a glass slide, and 

treat it with one drop of distillecl watery applying warmth. 
Concentrate the aqueous solution by evaporation, and 
allow crystals to form. These should be covered with 
thin glass, and subjected to microscopical examination. 
Chloride of sodium (§ 173), phosphate of soda (§ 155), 
sulphates of soda and potash (§ 169). {"Illustrations,'^ 
Urine, Plate I., Fig. 1). 

8. Earthy Salts. — If the saline residue is not entirely dissolved 

by water, add a drop of nitric acid, and observe whether in 
effervescence carbonate of lime occurs, or if the insoluble 
matter is dissolved without the escape of any bubbles of 
(jas, phosphate of lime. 

9. Uric Acii>. — Place about four ounces of urine in a beaker, 

add about a drachm of hydrochloric acid, and allow the 
mixture to stand for twelve hours. Crystals of uric or lithic 
acid (§ 137). 

10. Uric Acid. — To a small quantity of the urine, concentrated 

by evaporation, and placed in a watch-glass, add a few 
drops of acetic acid, and insert in the mixture a few fila- 
ments of tow or silk. Allow the whole to stand for twenty- 
four hours, covered with a glass shade, in order to prevent 
the entrance of dust (§ 137, 3). Crystals of uric or lithic acid. 

*** The deposits from the urine examined in §§9 and 10 are to be examined in 

Table II. 



EXAMINATION OF URINE. 413 



TABLE II. 



SYSTEMATIC QUALITATIVE EXAMINATION (Page 104). 
THE ORGANIC CONSTITUENTS (Chapter V., p. 71). 

11. Reaction. — Specific Gravity. — Ascertain the reaction and 

specific gravity of the specimen of urine, and note any 
general characters you may observe (Chapter V.). 

12. Place two portions, A and B, of about 300 grains each, in 

basins, to evaporate over the water-bath (§ 151, Figs. 3, 8, 
Plate I.), 

13. In Portion A. — Urea, Mcjcus, Uric Aoid, Extractive 

Matters, Earthy Phosphate, and Silica (§ 151). 

14. In Portion B. — Fixed Salts (Chapter VI.). 

B is to be placed in a platinum capsule and incinerated (Fig. 5, Plate I., 
§ 9). The saline residue is to be maintained at a red heat, and, 
when decarbonized, is to be preserved for examisation in Table III. 

Proceed with Portion A. 

15. Urea. — CgHANjOa. Extract A is to be treated with three 

successive portions of Alcohol^ about the sp. gr. '825, which 
are to be foiled upon the residue for a few minutes over 
the water-hath. The alcoholic solutions are to be mixed 
together and concentrated by evaporation. The extract is 
to be treated with a little water, in order that it may be 
reduced to the consistence oi syrup (§§ 126, 161). 

a. A little of the syrupy extract, when cold, is to be. 
placed in a small basin, and treated with a few drops of 
strong Nitric Add, nitrate of urea CaH4Na08,H0,N05. 
Examine the crystals thus formed in the microscope (§151, 
(*' Illustrations,^' Urine, Plate III.). 

b. The remainder of the concentrated extract is to be 
placed over a water-bath, conveniently arranged, and 
treated with crystals of oxalic acid until no more are 
dissolved at a temperature of 200°. The mixture is then 
permitted to cool; and, after the crystals have been slightly 
washed with a little distilled water, they may be placed 
between folds of filtering paper, oxalate of urea, CglllNsOs, 
HOjCgOa. Examine a few of the crystals in the micro- 
scope (" Illustrations,'^ Urine, Plate IV.). After having 
been well pressed, to absorb extractive matters, &c., the 
crystals are to be dissolved in warm water, and excess of 
carbonate of lime added to the solution, to decompose the 
oxalate of urea. When the mixture becomes neutral to test 
paper, it is to be filtered, and the clear solution, which 



414 TABLES FOB THE 

consists of niea, with a little colouring matter, concentrated 
by evaporation. Urea and oolouring matter remain. The 
latter may be removed by dissolving the urea in water, 
and boiling the solution with animal charcoal, and sub- 
sequent filtration (§ 161). 

The process of filtering is seen in Fig. 13, Plate III.; 
the manner in which the paper is folded, in Fig. 12, 
Plate II. The wash-bottle, for washing precipitates, is 
represented in Fig. 10. 

16. Mucus, LiTHio Acid, Eaktht Phosphate, and Silica. — 

The matter insoluble in Alcohol^ D (§ 151), is to be treated 
with hot water, to dissolve extractive matter, and filtered. 

The residue on the filter is to be dried, and incinerated 
on platinum foil. The xnncns and uric aeld are destroyed. 

When the residue, consisting of phoephate of lime and 
lilica is decarbonized, it is to be treated with a drop of 
nitrio acid. Observe whether effervescence occurs, carbo- 
nate of lime CaO,COa. A trace of silica remains undissolved 
(§ 161). 

To the acid solution add a drop of ammonia, and note 
the result. Examine the precipitate in the microscope, 
and notice the crystals of ammoniaco-magnesian or triple 
phosphate, and the amorphous granules of phosphate of lime 
(§162). {^^ Illustrations y" Urinary Deposits, Plate IX., 
Figs. 1, 2 ; Plate XXI., Fig. 4). 

17. Ubic Acid C10H4N4O6. — Examine the crystals deposited 

upon the sides of the vessel, and upon the filamants of tow 
or silk which were set aside in Table I., with the microscope, 
and note the form of the crystals (Fig. 67, Plate XL; Figs. 
105, 106, Plate XX., ^^ Illustrations,^^ Urinary Deposits, 
Plates v., VI., VII., VIIL). Then collect them upon a 
glass slide, and divide them into three portions. 

a. To the first add a little solution of potash, which 
dissolves the crystals, forming urate of potash, and after- 
wards excess of acetic C4H308,H0, or hydrochloric acid, 
HCl. After a few minutes have elapsed, subject the de- 
posit to microscopical examination. Crystals of lythic or 
uric acid CioH,:^^ (§ 137, 2, 3). 

h. To the second portion add a drop of nitric acid 
HOjNOs, evaporate the mass to dryness over the lamp, 
then allow it to cool, and add a little ammonia NH,, or 
expose the acid residue to the vapour of ammonia. A 
beautiful purple colour, owing to the formation of murezide 
CiaNjIleOg results (§ 137, 1 ; § 398). 

c. To the third portion add solution of carbonate of 
potash K0,C0a-H2Aq, which will dissolve the uric acid 
CWH4N4O6, but more slowly. 



EXAMINATION OF URINE. 415 



TABLE III. 



SYSTEMATIC QUALITATIVE EXAMINATION (§ 183). 
THE SALINE CONSTITUENTS (Chapter VIL), 

18. Alkaline and Earthy Salts. — Treat the residue resulting 

from the incineration of portion B in Dem. II. with boiling 
distilled water and filter (§ 183) ; reserve the residue for 
subsequent operations (No. 23, below). Proceed with the 
clear solution, which is to be divided into two parts, one 
consisting of three-fourths and the other of one-fourth. 

The fourth part of the solution is to be divided into three equal portions 
(No. 21). 

ALKALINE SALTS. 

19. Sulphuric Acid. — To about three-fourths of the clear so- 

lution add a few drops of nitric acid, HOjNOg, and observe 
if effervescence occurs, carbonate of soda NaO,COa 4 lOAq. 
Next add to the solution, placed in a flask and heated over 
a lamp, a small quantity of a solution of chloride of barium, 
BaCl + 2 Aq. Boil the mixture and separate the precipitate 
by filtration. Sulphate of baryta, BaO,S08 (§ 169). 

While filtration is proceeding, pass on to No. 21. 

a. A small quantity of the white precipitate of sulphate 
of baryta is to be boiled in caustic potash, and another 
portion in strong nitric acid. It is insoluble in both. 

20. Phosphoric Acid. — The solution filtered from the precipi- 

tate produced by chloride of barium is to be treated with 
excess of ammonia NH, and the mixture rapidly filtered, 
avoiding exposure to air as much as possible. Phosphate of 
baryta 2BaO,HO,P05 (§ 168, 183).— Concentrate the clear 
solution by evaporation, and when reduced to a small bulk 
continue its further examination (No. 22). 

21. Chlorine, Phosphoric Acid. — To the first portion add a 

few drops of nitric acid and excess of a solution of nitrate 
of silver AgO,N05, chloride of silver AgCl (§ 175). Filter. 
To the solution carefully add ammonia, avoiding aft excess, 
phosphate of silver 3Ag0,P05. Then add more ammonia, 
and afterwards nitric acid (§ 183). 

Phosphate of silver \s soluble in ammonia and also in 
nitric acid. 

Chloride of silver is soluble in ammonia, but insoluble 
in nitric acid. 



41G TABLES FOB THE 

a. Phosphoric Acid of the alkaline phospTiates pre- 
cipitated as ammoniaco-magnetiaiL or triple phosphate. To 
the second portion add a little of a solution of muriate of 
ammonia lslli,C\, ammonia NHg, and sulphate of magnesia 
MgOjSOs. A precipitate of phosphate of amnioTiia and mag- 
nesia will take place, ,MgO,NH40,P05. This is insoluble 
in ammoniacal salts (§ 164). 

h. Phosphoric Acid of the alkaline pliospliate pre- 
cipitated as phosphate of lime. To the third portion of the 
clear solution add a little of a solution of ehlortde of calcium 
CaCl, and ammonia NH,. Phosphate of lime ,CaO,HO,POs 
is precipated. 

Allow the two last precipitates to snbside, and then remore a little 
with the pipette and sabject them to microBcopieal esamination. 
Phosphate of lime is amorphoas, but the ammoniaoo-magneaian 
phosphate is crystalline (§166^. (*' IHustratians of Urinary Dt- 
posiur Plate IX., Figs. 1, 2 ; XXI., Fig. 4.) 

22. Potash, Soda. — Return to the examination of the solution 
obtained in No. 20, in which the presence of potash KO 
and soda KaO is to be demonstrated. Add it to an excess 
of ammonia NH3, and carbonate of ammonia 2NH40,3C0j, 
in order to precipitate the excess of baryta BaO. Filter. 
Evaporate the solution to dryness and gently ignite the 
residue in a platinum capsule. Dissolve what remains in 
water, and add a few drops of solution of bichloride of 
platinum PtClg. Evaporate the mixture to dryness over 
the water bath (p. 128). 

The dry residue is to be treated with successive portions 
of aUohol. Fotassio-chloride of platinum KCl,PtCl2 remains 
undissolved (p. 128). 

The alcohhlic solution is to be concentrated that crystals 
may form, sodio-chloride of platinum NaCljPtClg. Examine 
both the crystalline deposits in the microscope under the 
influence of polarised light. 

The crystals of potaasio-chloride of platiniun are octohedrtd and do not 
polarise, while the crystals of sodio-chloride of platinum are. 
aciculat\ and do polarise. 



EARTHY SALTS. 

23. Phosphate of Lime, Phosphate of Ammonia and Mag- 
nesia. — Return to the examination of that portion of the 
saline residue insoluble in water (No. 18). 

Add a few drops of 7iitric acid KO5 to the residue, and 
notice if effervescence takes place, carbonate of lime CaO, 
COg. Dilute the solution and filter. Reserve any insoluble 
matter for further operations (No. 24). 

a. To one portion of the clear solution add excess of 



EXAMINATION OF URINE. 417 

ammonia NHjh and examine the precipitate in the micro- 
scope. Phosphate of lime 8CaO,3P05, and phosphate of 
ammonia and magnena 2MgO,NH40,P05 + 12Aq (§ 164). 

b. LiHE, Magnesia.-— To another portion of the acid 
solution add ammonia NHg, and afterwards excess of 
acetic acid CaHsOsjHO, and then oxalate of ammonia 
NRfififii+Aq, oxalate of lime CaO,Cs,0^ Boil and 
filter (p. 127). 

Concentrate the clear solution by evaporation. When 
cold, add a little solution of chloride of ammonium NH4CI, 
and phosphate of soda aNaO,HO,P05+24Aq. Well stir 
the mixture, and examine the crystalline deposit in the 
microscope. Triple or ammoniaco-magnesian phosphate 
2MgO,NH40,P05 + 12Aq. (" Illustrations of Urinary De- 
posits'', Plate IX., figs. 1, 2.) 

24. Silica. — That portion of the earthy salts insoluble in water 
is to be boiled with a few drops of strong nitric acid, HO, 
NO5, silica^ SiOs remains undissolved (p. 127). 

In the Systematic Qualitative Examination op Healthy 
Urine, commenced in Table II., the presence of the following 
substances has been demonstrated : — 

In portion A, 

Urea Muoils Earthy phosphates 

Uric acid Extractive matters Silica 

In portion B, 

Chlorine Potash Magnesia 

Sulphuric acid Soda Silica 

Phosphoric acid Lime 

See also forms in pp. 106 and 129. 



418 TABLES FOB THE 



TABLE lY. 

SUBSTANCES HELD IN SOLUTION IN MORBID URINE 
(Chapters IX., XI., XU.). 

EXCESS OF UREA, ALBUMEN, BILE. 

25. Ascertain the reaction and specific gravity of the specimens 

of Urine marked A, B, C, D. 

26. Albumen. — Boil a portion of the urine in a test-tube over a 

spirit lamp and observe the character of the precipitate, 
if one is formed. 

a. Treat a second portion with about ten drops of nitric 
acid (§241). 

If no precipitate is produced upon the addition of nitric add, or upon 
the application of heat, pass on to No. 27. 

b. A third portion to be treated with half its bulk of 
strong nitiic acid, and boiled. 

c. To a fourth portion add two drops of very dilute 
nitric acid, and afterwards boil. 

A yery dilute solution of nitric acid preyents the precipitation of albu- 
men by heat (§248). 

d. A fifth portion is to be treated with a little acetic 
acid H0,C4H303, and afterwards a solution of ferrocyanide 
of potassium Ka,FeCy8 + 3Aq is to be added (p. 138). 

e. To a sixth portion add a solution of bichloride of 
mercury HgCla (§250). 

27. Excess op Urea CaH^NaOg. — Add to the specimen of urine 

suspected to contain excess of urea from its deep colour 
and high specific gravity, about half its bulk of nitric acid 
HOjNOg. Allow it to stand for a few minutes, and examine 
the crystalline deposit which forms in the microscope, 
nitrate of urea, CaH^NAjNOs (§206). 

28. Sugar. — a. A portion of the urine suspected to contain 

sugar is to be boiled in a test tube with half its bulk of 
solution of potash KO,HO (Moore s test). If it becomes 
of a dark reddish brown colour from the formation of 
melassic or sacchulmic acid, it is to be treated with excess 
of nitric acid, when the peculiar odour resembling that of 
molasses will be produced, and the dark brown solution 
will become perfectly clear (§ 276). 



EXAMINATION OF URINE. 419 

b. A second portion is to be treated with one or two drops 
of a solution of sulphate of copper CuO,S08 + 5 Aq., and 
afterwards a considerable excess of potash KO,HO is to be 
added. The dark blue solution is then to be heated over 
the spirit-lamp and boiled for a moment, when a yellowish 
brown precipitate of suboxide of copper CusO, will be 
produced [Trommer^s test] (§ 277). 

c. A third portion is to be heated with about an equal 
bulk of the solution of tartrate of copper in potash, 
Barreswil^s solution (§ 278). 

d. Fermentation.— Fill one of the tubes placed on the 
table with urine, and the other with water, to each add 
six drops of yeast, and then a little more urine and water, 
in order that the fluids may rise above the brim of the 
tubes. Apply the india-rubber pad, and invert them in 
the small beakers. Remove the india-rubber, and add 
some mercury. Place the whole in a temperature of 80°, 
and, after the lapse of two hours, compare the size of the 
bubbles of gas in the respective tubes (§ 283). 

e. Crystals. — Allow a few drops of diabetic urine to 
evaporate spontaneously upon a glass slide, and examine 
the residue on the next day to see if crystals have formed 
(§ 274, Plate XIIL, Fig. 66). 

29. Bile. — a. One portion of the urine is to be placed in 
a test-tube, and after the addition of one drop of syrup, 
two-thirds of its bulk of strong sulphuric acid SOgHO are 
to be added cautiously by drops. Shake the mixture, and 
allow it to stand for a few minutes. If sufficient heat is 
not produced by the addition of the acid, warm the tube 
slightly over the lamp. The mixture becomes of a dark 
violet colour, which, however, is destroyed by a tempera- 
ture a little above 140* [Pettenhofer's test] (p. 144). 

b. Pour a few drops upon a clean white plate, and after 
spreading it over the surface, allow a drop of nitric acid to 
fall in the centre. Observe the play of colours (§ 258 a). 

c. To another portion add a few drops of serum, and, 
after agitation, a little nitric acid NOgjHO. Observe the 
colour of the coagulated albumen [Heller's t^st] (§ 259). 



420 TABLES FOB THE 

TABLE y. 

CHEmCAL EXA^HNATION OF URINARY DEPOSITS. 

III.— SECOND CLASS OF URINARY DEPOSITS (Chapter XV.) 

PUS, URATES, PHOSPHATEa 

30. Observe the characters of the urinary deposits in the 
glasses A, H, C, and note the colour, reaction, and specific 
gravitij of each specimen. 

8L Aftbb having poured off the supernatant fluid, take about 
one-fourth of the deposit from each glass, and pour it into 
a test-tube. Add to it about half its bulk of solution of 
2)otash K0,H0. 

Pus is rendered transparent, viscid, and glairy by 
potash (§ 374). 

Urates dissolved by potash. Solution ol^ar and limpid. 

Phosphates are not affected by potash, 

82. Ubates ob Lithates. — If the deposit be soluble in potash 
KO, and is not rendered glairy, take another portion and 
heat it in a clean test-tube with a little water. It vrill be 
dissolved upon the application of a gentle heat, and will 
be precipitated again when the solution becomes cool. 
Another portion may be dissolved in potash KO, and then 
excess of nydrochloric acid HCl, or ascetic acid C4H3O3,H0, 
added. After the lapse of ten or twelve hours the deposit, 
consisting of uric acid CioH^N^Oa, may be subjected to 
microsnopical exnmination, or tested in the manner 
described in No. \l,a,h (§ 137). 

33. Pus. — If the deposit be rendered glairy by potash KO, note 

carefully its viicroscopiad characters under the quarter of 
an inch object glass, and then add a drop of acetic acid 
C4H303,H0, and observe the change which takes place in 
the appearance of the corpuscles. Notice if any crystals 
of triple phosphate sMgO,NH40,P06 + 12Aq. are present in 
the deposit, and observe the character of any epithelium 
that may be met with (§§ 383, 384). 

A small portion of the supernatant fluid is to be treated 
with nitric acid HOjNOs, and another portion boiled in a 
test-tube. The precipitates consist of albumen (§ 383). 

34. Eabtht Phosphates. — If the deposit consists of earthy 

phosphates, it will not be altered by potash KO, nor by 
the application of heat. A portion of it is to be treated 
with nitric acid H0,N05, in which it is soluble without 



EXAMINATION OF URINE. 421 

effervescence.* Observe its microscopical characters (§ 246). 
If there are no well-defined crystals dissolve a portion in 
dilute nitric acid, and then add excess of ammonia. Upon 
microscopical examination, the precipitate will be' found to 
consist of feathery crystals of triple phosphate and granules 
of phosphate of lime (§§ 164, 388). 

IV.— THIRD CLASS OF URINARY DEPOSITS. 
(Chapter XVI.) 

URIC OR LITHIC ACID, OXALATE OF LIME, SAND. 

35. Observe the character of the deposits in the glasses D, E, F, 

and note the colour, reaction, and specific gravity of the 
fluid in each case. 

36. If the Deposit is very small in quantity, remove it in the 

manner described in §§ 54, 65, and place it in a small 
watch-glass or in the cell (Plate V., Fig. 25). 

XTric or lithic aoid is dissolved by potash, while oxalate 
of lime and sand are not affected by this reagent. Oxalate 
of lime is insoluble in acetic acid and potash, but is dis- 
solved by nitric add. Sand is not affected by potash, nor 
by strong nitric acid, 

37. Uric or Lithio Acid CioHiN^Oa. — If the deposit is soluble 

in potash KO, treat a portion of it with nitric acid HOjNOg, 
upon a glass slide, and carefully evaporate it to dimness 
over the spirit-lamp. When cool, expose the residue to 
the vapour of ammonia, or add to it a drop of that reagent. 
The beautiful purple colour which results depends upon 
the formation of Murexide CuNsHaOa (§ 17, a, b, c, § 137, 
" Illustrations;' Plate IV., V., VL). 

38. Oxalate oe Lime CaOjCaO, + 2Aq. — ^If the deposit is in- 

soluble in potash KO, and also in acetic acid C4H308,H0, 
but is dissolved by nitric acid H0,N06, collect a portion of 
it upon a filter, and after having been well washed, let it be 
dried and carefully incinerated on platinum foil. To the 
white ash add a drop of acetic acid, and note the result, 
Examine a portion of the original deposit in the microscope 
(p. 297, "Illustrations;' Plate XL, XII.). 

Oxalate of lime is decomposed, at a dull red heat, into 
carbonate of lime CaO,COs. 

39. Sand. — If the deposit is insoluble in potash KO,HO, acetic 

acid C4H808,H0, nitric acid H0,N05, boil it in strong nitric 
acid, and examine it under the microscope. 

♦ If eflFervescence occurs upon the addition of nitric acid, it probably depends upon 
the presence of carbonate of ammonia, resulting;; from the decomposition of urea, a 
change very liable to occur in disease of the bladder, in which case the mucus appears 
to act the part of a ferment. 



422 TABLES FOR THE 



TABLE VI. 

THE EXAMINATION OF SMALL QUANTITIES OF 
DEPOSITS. 

URINARY CALCULL 

1. Calculi which are not destroyed by a red heat, 

Xnoombiutible Calonli. 

FhoBphate of lime 8Cao,3POs; phoBphate of ammonia and magnesia 
or triple phosphate 2Mg0,NH40,F0s ; fosible oalcnlns consisting of a 
mixture of phospate of lime and triple phosphate. 

2. Calculi which are partially decomposed^ or entirely destroyed 
by a red heat. 

Combustible or partially Combustible Calculi. 

Uric or Uthic acid C10H4N4O6; uric or Uthate of ammonia 
NH40,CioH4N406; urate of lime CaO,CioH4N406 ; oxalate of lime 
CaOCA; cystine CeNHeO^Sg. 

If the calculos consists of sereral different layers, a portion flrom each 
layer shonld be finely powdered and examined separately. 

Microscopic Calculi. — Plate XXIII., Fig. 124, ^^Illustrations,'' 
Calculi, Plate I. 

40. Urinary Calculi. — Heat a portion of the calculus, about 

the size of a pin's head, on platinum foil, over the spirit- 
lamp. Expose the black ash thus obtained for some time 
to a dull red heat until the residue becomes white. If 
there should be no fixed residue pass on to No. 44. 

Calculi which leave a Fixed Residue. 

41. Fusible Calculus. — The white ash is to be exposed to the 

heat of the blow-pipe flame. Observe if it be fusible or 
infusible. 

42. Phosphate op Limb, AMMONiAco-MAaNESiAN Phosphate. 

The ash is to be dissolved in dilute hydrochloric acid 
HC1,H0. If effervescence occurs upon the addition of the 
acid pass on to No. 43. Neutralise with ammonia NH,. 
Examine the precipitate in the microscope. 391. Sect. 246. 
a. Carbonate of lime results from the decomposition of 
oxalate of lime, miilberry calculus, at a red heat. 



EXAMINATIOM OF URIN£. 423 

43. Oxalate op Limb. — If effervescence occurred upon the 

addition of the acid, the solution is to be neutralised with 
ammonia, and afterwards excess of acetic acid added. To 
the solution add oxalate of ammonia NH^OjCjOs+Aq, 
oxalate of lime Ca^OCsOs is thrown down. This is insoluble 
in potash KO,HO, and in acetic acid H0,C4H8O8, p. 399. 

Calcali which leave scarcely a trace of Fixed Besidoe. 

44. Ubatb Calculus. — A small portion of the calculus finely 

powdered is to be treated with hot water. If soluble in 
that fluid a strong solution of carbonate potash is to be 
added, ana the tube heated over the lamp. Ascertain the 
reaction of the fiimes which are given off. Notice their 
smelly and hold a hot rod which has been dipped in hydro- 
chlonc acid over the mouth of the tube. 

45. Urio Acid Calculus. — If insoluble in water also add a 

little potash. If soluble in the last reagent, treat another 
portion of the calculus with nitric acid and ammonia, as 
described in No. 17, b. This test may also be applied in 
case of a calculus supposed to consist of urate of ammonia. 

Method op Testing very small Quantities op Matter with 
Reagents kept in small Bottles with Capillary Oripices 
(Plate v., Figs. 27, 28, 30). 

46. Phosphate op Lime, Chloride op Sodium, Phosphate 

OP Soda, Sulphate op Potash. — ^What is the nature of 
the substance upon the glass slides marked A, B? Test it 
with such reagents as you think requisite. 

What substances are dissolved in the drops of water 
marked CjD.E? 



424 



MICROSCOPICAL AND CHEMICAL EXAMINATION OF 
THE URINE IN DISEASE. 



TABLE VII. 

The Microscopical Examination op Urinaey Deposits. 

InBoluble matters and urixiary deposits (Chapters XIII. to 
XVL). 

Insoluble Matters may be divided into four classes (p. 290) : — 

1. Insoluble Matter Floating upon the Surface 
OP Urine, or Dippused through the Fluid. 

2. Light and Flocculent Deposits, Transparent 
AND Occupying Considerable Bulk (§§ 324, 325). 

3. Dense and Opaque Deposits, Occupying Consi- 
derable Volume (374). 

4. Granular or Crystalline Deposits, Sinking to 
THE Bottom, or Deposited upon the Sides op the 
Vessel (§ 231). 

Many of the most important urinary deposits are scarcely visible to the 
unaided eye, and can only be detected by careful microscopical 
examination. 

For collecting urine for microscopical examination, see § 52. 

In examining a specimen of urine the microscopical characters of the 
pellicle upon the surface of any insoluble matter diflFused through the 
fluid, us well as those of the deposit^ should be noticed. In many 
instances also it is necessary to examine the deposit in its upper part 
as well as that portion which sinks to the bottom of the vessel. 

It is most important to be acquainted with the characters of those 
extraneous matters which are liable to fall into the urine acciden- 
tally, or which may have been placed there for the purpose of 
deceiving the practitioner. These are enumerated in § 78. 

The chemical reagents required for examination are contained in the 
small bottles with capillary necks ($§ 1, 34, Plate V., Figs. 27, 28, 30). 

47. With the pipette (§ 22) remove a portion of deposit from the 
urine in the different conical glasses (Plate I., Fig. 6 ; II., 
Fig. 9), and place it upon a glass slide or in a thin glass 
cell or in the animalcule cage (Plate V., Figs. 24, 25, 26), 
and when carefully covered with thin glass, subject it to 
examination with the quarter of an inch object glass (p. 56). 
What is the nature of the nrinaiy deposits in the glasses 
numbered from 1 to 6, and the extraneons matters in 
glasses 7 to 12?* 

• The nature of the substances placed in the glasses is seen by reference to the 
following sections. They must be prepared beforehand by the teacher. 



MICROSCOPICAL EXAMINATION. 425 

1. — Diffused through the urine, and not forming a distinct 
deposit ; or, forming a thin stratum or pellicle upon the 
surface of the urine. 

48. Urates (§ 375). (" Illustrations;' Plate VIII. ; Figs. 1, 2, 5, 6). 

Fatty matter in a state of extremely minute division, as 
it occurs in chylous urine (§ 330, Plate XV., Fig. 72). 

Vibriones, usually present only in urine which has been 
kept for some time, out occasionally found soon after the 
urine has been passed (§ 349, Plate XV., Fig. 73). (" Illus- 
trations;' Plate XIX., Fig. 3.) 

49. Film composed of pboBphate of lime and ammoniaco-magnesian 

or triple phosphate, not unfrequently containing oil-globules 
(§§ 324, 339). 

Torulee occurring in diabetic urine (§§ 275, 360). 

2.— First Class of Urinary Deposits (Chapter XIV., p. 289). 

60. Mucns (§ 344, Plate XVII., Fig. 85). 

Epithelium — from the convoluted portion of the urine- 
ferous tubes ; from the straight portion ; from the pelvis of 
the kidney ; from the ureters ; from the bladder ; from the 
urethra (§353); from the vagina (§354); epithelii^m con- 
taining oil (§367, Plate XVlll., Fig. 90). ('^Illustrations;' 
Plate XXIV.) 

Spermatozoa (§358, Plate XVI., Fig. 81). {''Illustra- 
tions," Plate XIII.) 

Vibriones (p. 265). (''Illustrations;' Plate XIX., Fig. 3.) 

Tomlee — sugar torulu ; penicilium glaucum (§ 350). 
(" Illustrations," Plate XIX., Figs. 4, 5, 6.) 

Saroina (p. 258). {''Illustrations," Plate XIX., Fig. 2.) 

Casts of the uriniferous tubes (§ 363). Casts of medium 
diameter, about the l-700th of an inch (§ 364). 

EpUMidl casts. Pale and slightly granular casta OrantUar casts. 
Casts containing pus, bloody crystals of oxalate of lime^ or lUhic add. 
Casts containing <nl (§§367, 369, 370, Plate XVIIL, Pigs. 87, 89, 90, 
91). C' Illustrations," Plate XIV., Figs. 1, 2 ; Plate XVIIL, Fig. I.) 

Casts of considerable diameter, about 1-500^^ of an inch. 

Large and perfectly transparent casts. Darkly granular casta Casts 
containing nnmeroas ceUs, often enclosed, as it were, in a perfectiy 
transparent tube (§371, Plate XVII., Fig. 86). {"* lUustrations," 
Plate XIV., Fig. 5 ; Plate XVI.) 

Casts of small diameter, about the 1-1000^^ of an inch. 

Small waxy casts, perfectly clear in every part, or slightly granular in 
•some places (Plate XVUI., Figa 88, 91). Q'lUustrations," Plate 
XIV., Fig. 6.) 



426 MICROSCOPICAL EXAMINATION. 

3. — Second Class of Urinary Deposits (Chapter XV., p. 313). 

Urate of loda with various colouring matters — red, pink, 
nut-brown, <bc., with small quantities of urates of ammonia^ 
lime, and magnesia (§ 376). (" Illustrations^' Plate VIIL, 
Figs. 1, 2, 6, 6.) 

Pns (§ 381, Plate XIX., Figs. 93, 94, 95, 96, 97, 98, 99). 

Phosphatei, consisting of phosphate of lime and phosphate 
of ammonia and magnesia, or triple phosphate (§§ 387, 390, 
Plate XIX., Fig. 98*; Plate XX., Figs. 101, 102, 103). 
(" Illustrations;' Plate IX., Figs. 1, 2.) 

4. — Third Class of Urinary Deposits (Chapter XVI., p. 313). 

Uric or lithic acid in various forms (§ 397, Plate XX., 
Figs. 105, 106). {''Illustrations;' Plates IV., V., VI., VII.) 

Oxalate of lime occurring in the form of octohedra 
(§402), or of dumb-bells (§404, Plate XXI., Figs. 107, 108, 
109, 112 ; Plate XXIIL, Figs. 124, 125, 126). {''lUus- 
trations;' Plates XII., XIII.) 

Cystine (§ 411, Plate XIV., Fig. 71*). {''lUustrations;' 
Plate X.) 

Carhonate of lime (§ 414). 

Blood corpuscles (§ 416, Plate XXI., Fig. 111). 

61. The most Important Extraneous Matters accidentally 
present in the urine, or which are sometimes added for the 
purposes of deceiving the practitioner, are the following 

(§78):— 

Human hair ( § 80, Fig. 38, Plate Milk and certain colouring matters 

VII. a). (§42). 

Cat's hair (Fig. 38 b). Oily matter (Fig. 38 i). 

Blanket hair (Fig. 38 c). Potato-starch (Fig. 37, § 85). 

Worsted (Fig. 38 c). Wheat-starch. 

Wool. Bice-starch. 

Cotton and flax fibres (Fig. 38 d e). Tea-leaves. 

Splinters of coniferous wood swept Bread-crumbs (Fig. 38 h). 

from the floor (Fig. 36). Chalk or whiting. 

Portions of feathers (Fig. 38^). Sand. 

Fibres of silk. Peroiude of iron (§ 79). 

See also ^' Illustrations ;' Urinary Deposits, Plates I., II., III. 



427 



WEIGHTS AND MEASURES. 



TROY OB APOTHBCABIBS WEIGHT. 



Pound. 


Ounces. 


Drachms. 


Scruples. 


Grains. 


French Grammes. 


1 


= 12 = 


96 = 


288 


= 5760 


= 


372-96 




1 = 


8 --= 


24 


= 480 


= 


31-08 






1 = 


3 


60 


= 


3-885 








1 


20 

1 


= 


1-295 
0-0647 






ATOIRDUPOIS WEIGHT. 






Pound. 


Ouncea 


Drachms. 


Grains. 


French Grammes. 


1 


16 


256 


= 


7000 


= 


453-25 




1 


16 


= 


437-5 


= 


28-328 



1 



27-343 



1-77 



Gal 

1 



IMPERIAL MEASURE. 

Pints. Fl. ounces. Fl. drms. Minims. 

8 = 160 = 1280 = 76800 

1 = 20 = 160 = 9600 

1 = 8 = 480 

] = 60 

WEIGHT OP WATER AT 62°, CONTAINED IN THE IMPERIAL 
GALLON, &0. 

Grains. 

Imperial Gallon = 70,000 

„ Pint = 8,750 

„ Fluid Ounce = 437-5 

„ Fluid Drachm = 54*7 

„ Minim = 0*91 

CUBIC INCHES CONTAINED IN THE IMPERIAL GALLON, &0. 

Cubic Inches. 

Imperial Gallon = 277*273 

„ Pint = 34-659 

„ Fluid Ounce = 1*732 

„ Fluid Drachm = 0*2166 

„ Minim = 00036 



428 



FRENCH WEIGHTS AND MEASURES. 



MEASUBES OP LENGTH. 







English Inches. 














Millimetre 


= 


•03937 














Centimetre 


= 


•39371 














Decimetre 


= 


3-93710 














Metre 


= 


39-37100 




MU. 


Fur. 


YdB. 


Feet. 


In. 


Decametre 


= 


393-71000 


= 








10 


2 


9-7 


Hecatometre 


= 


3937-10000 


= 








109 


1 


1 


Kilometre 


= 


39371-00000 


= 





4 


213 


1 


10-2 


Myriometre 


= 


39371000000 


= 


6 


1 


156 





6 



MEASURES OP CAPACITY. 







Cubic Inches. 




Gal. 


English Imperial Measure. 
Pts. F. oz. F. drm. 


Min. 


Millilitre 


= 


•06102 


= 














16-3 


Centilitre 


= 


•61028 


= 











2 


42 


Decilitre 


= 


6-10280 


= 








3 


3 


2 


Litre 


= 


61-02800 


= 





1 


15 


1 


43 


Decalitre 


= 


610--28000 


= 


2 


1 


12 


1 


16 


Hecatolitre 


= 


6102-80000 


= 


22 


2 


1 


4 


48 


Kilolitre 


= 


61028-00000 


= 


220 





12 


6 


24 


Myriolitre 


= 


610280-00000 


= 


2200 


7 


13 


4 


48 



MEASURES OP WEIGHT. 







English Grains. 










Milligramme 


= 


-0154 










Centigramme 


= 


•1544 










Decigramme 


= 


1-5444 






Avoirdupois. 




Gramme 


= 


15-4440 




Pound. 


Ounce. 


Drachm. 


Decagramme 


= 


154-4402 


= 








5-65 


Hecatogramme 


= 


1544-4023 


= 





3 


8-5 


Kilogramme 


= 


15444-0234 


= 


2 


3 


5 


Myriogramme 


= 


154440-2344 


= 


22 


1 


2 



429 



ADDENDA, 



The Estimation of Albumen.— Hoppe recommends the deter- 
mination of albumen by the polarising apparatus (Virchow's 
"Archiv." Vol. II., p. 674). Boedecker states that albumen may 
be estimated quantitatively by employing a graduated solution of 
ferrocyanide of potassium (Henlc and Pfeufer's ^' Zeitschrifty'' 1859, 
p. 321) ; but Vogel says that in his hands the results were very 
unsatisfactory. 

Estimation of Phosphoric Acid. — In addition to the volu- 
metric process described on page 16, another plan has been proposed 
by Mr. Sutton {see Sutton's " Volumetric Analysis'') ; Neubauer also, 
about the same time, employed a similar process. The phosphoric 
acid is estimated as a phosphate of uranium. I have not yet tried 
this process, but it is stated to be very accurate. Any description 
would be useless without detail. I therefore refer those who desire 
to employ this plan practically, to Dr. Markham's translation of 
Neubauer and Vogel, just published by the new Sydenham Society, 
page 190, or to Mr. Sutton's work. 

Dr. Edward Smith's Observations on the action of Tea 
(omitted on page 91). — Dr. E. Smith states that tea and coffee 
excite respiration and increase the quantity of carbonic acid ; that 
tea increases waste, and excites every function of the body ; and 
that it is, therefore, injurious to those who are not well fed. These 
conclusions are at variance with the results of Dr. Bocker (p. 91), 
who found that tea caused a diminution in the quantity of per- 
spiration, urea, and the faeces. B5cker states that it does not 
influence the amount of carbonic acid formed, nor the frequency of 
the pulse or respiration ; and that when the diet was insuflSicient, 
tea prevented the loss of weight being so great as it would otherwise 
have been. 



INDEX 



Abnormal deposit in urine, 76. 

Abscesses in kidney, 824. 

Acetate of lead in dissolving calculi, 359. 

Acetone, 265. 

Acid, biliary, detection of, 211. 

carbonic, in urine, 84. 

increase of; in urine, 1 19, 148. 

lactic, in urine, 103. 

nitric, in urine, 148. 

Dr. Bence Jones on, 148. 

phosphate of lime, 116. 

phosphoric, 110. 

sulphuric, as a test for bile, 211. 

uric, 36, 96, 337. 

Acids in urine, 78. 

organic, in urine, 104. 

vegetable changes of, in organism, 

81. 
Acidity of urine, influence of liquor 

potassae on, 91. 
Ajfue, urine in, 203. 
Albumen in urine, 193. 
' importance of, in a clinical point 

of view, 201. 

peculiar forms of, 199. 

substances allied to, 200. 

estimation of quantity in urine. 



199, 429. 

in the urine, its connexion with 



kidney disease, 203. 

in diabetic urine, 220. 

■ and common salt, their influence 



on the specific gravity of urine, 77. 

with urates, 317. 

conversion of, into urea, 88. 

dissolves phosphate of lime, 329. 
• in urine in acute rheumatism. 



204. 



- not coagulated by heat when a 
trace of nitric acid is present, 197. 

containing blood, 205. 

resembling uric acid, 195. 



• phosphates mistaken for, 116. 
- in pneumonia, 205. 

• in puerperal fever, 412. 

• containing pus, 320. 



Albuminuria, treatment of, 205. 
Alcapton in urine, 260. 



Alcohol extract, 101. 

its influence on the solids and 

fluids of urine, 91. 

in dUbetes, 258. 

Aldridgb, Dr., on formation of oxalic 
acid, 351. 

Alkalies, their action as diuretics, 63. 

their influence on the chemical 

changes, 90. 

Alkaline phosphates in urine, 119. 

tests for, 110. 

reaction of urine, 150. 

solution of albumen not pre- 
cipitated by heat, 194. 

urine, 80, 150. 

Dr. Rbbs on, 150. 

- in dyspepsia, 150. 



water in calculous disorders, 357. 

Allantoin, 265. 

Allarton, Mr., on lithotomy, 360. 
Almond cakes for diabetic patients, 287. 
Alumina, 125. 

Ammoniaco-magnesian phosphate, 117. 
Ammonia, formation of nitric acid from, 

149. 

in breath, 154. 

in urine, 85, 86, 152. 

in the breath, detection of, 154. 

Ammonium, chloride of, its influence in 

preventing the precipitation of suboxide 

of copper, 228. 
Amyloid or glucogenic matter, 236. 

formation of, in the liver-cell, 



240. 



- Dr. McDonnell on, 243. 



Anaesthesia, sugar in urine in, 166. 
Analysis of albuminous urine, 22a 

of chylous urine, 272. 

of diabetic urine, 252, 254. 

of healthy urine, qualitative or 

quantitative, 104. 

of urine containing sarcinse, 296. 

of urine containing cystine, 354. 

of urine containing urates, 317. 

volumetric, 10. 

- outline of, of urine in disease to 



be filled up, 190. 
Animal matter in calculi, 372. 



INDEX. 



431 



Anoxidic substances, 108. 

Apparatus for volumetric analysis, 12. 

examining urine, 1. 

Absdale, Dr. Van, on albumen in the 
urine in pregnancy, 204. 

Arteries of kidneys, 47. 

— — — straight, in pyramids of kidney, 
51. 

Artificial urea, 88. 

Arseniuretted hydrogen, influence on 
colouring matter of urine, 161. 

Average composition of healthy urine, 130. 

quantity of constituents elimi- 
nated in twenty-four hours, 137. 

Balance, 2. 

Balfour, Dr., on small organic globules, 



365. 



- on origin of pus, 320. 



Barlow, Dr., on ascertaining the seat of 
obstruction in intestines, 65. 

Barreswil's solution for estimating su- 
gar, 225. 

Basement membrane of tubes of kidney, 
52. 

Bash AM, Dr., on colour of albuminous 
precipitate, 210. 

Barry, Dr., on cystine, 354. 

Bath, influence of, on organic matter of 
urine, 167. 

Beakers, 4. 

Beohamp on the formation of urea, 88. 

Benekb, Dr., on acidity of urine, 79. 

on oxalate of lime in urine, 

352. 

Berlin, M., on test for sugar, 153. 

Bernard, M., on diabetes, 236. 

Bidder and Schmidt on formation of uric 
acid, 97. 

Bile in urine, 209. 

clinical importance of, 212. 

yellow precipitate produced by ace- 
tate of lead in urine containing, 211. 

Biot on estimating sugar by the sac- 
charimeter, 233. 

Bird, Dr., Golding, case of kiestein, 285. 

Bismuth test for sugar, 231. 

Black pigment in urine, 161. 

Bladder, epithelium from the, 299. 

chronic inflammation of, 323. 

injecting with water, 327. 

treatment of disease of, 326. 



- irritable, 293. 



Blister fluid, detection of uric acid in, 96. 
Blood calculi, 378. 

chlorides in, in pneumonia, 172. 

colouring matter of, in urine, 161. 

corpuscles, 357. 

in casts, 309. 

colouring matter of urine 

formed from, 74. 

in chylous urine, 270. 

preservation of, 36. 

course of, in kidney, 49. 

urea in, detection, 92. 

Blot, M., on Reynoso's observations on 

sugar in urine, 250. 



Blowpipe. 4. 

BocKER, Dr., on the influence of tea, 

coffee, and alcohol, 91. 
— — on influence of sugar on 

earthy phosphate, 189. 
Bodo urinarius in urine, 296. 
Bottle, specific gravity, 5. 
Bottles for carrying specimens of urine 

in, 25. 

with capillary orifices, 8. 

Brain, urine in chronic inflammation of, 

182. 
Bran in diabetes, 256. 
Bread containing alumina, 125. 

substitutes for, in diabetes, 256. 

Breath, ammonia in, 1-54. 

Breed and Winter on the quantity of 

phosphoric acid, 113. 
Briqht's disease, nature of, 69. 
Brodie, Sir Benjamin, on the solution of 

calculi, 404. 
Brijcke's test for grape sugar, 229. 
BuDD, Dr. 6., his conical glasses, 4. 
Dr. W., on a deposit of benzoic 

acid in the urine of gout, 165. 
pn urea